Healthcare Provider Details

I. General information

NPI: 1780855171
Provider Name (Legal Business Name): ESTHESIA ORAL SURGERY CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W 66TH ST SUITE 270
EDINA MN
55435-2111
US

IV. Provider business mailing address

3400 W 66TH ST SUITE 270
EDINA MN
55435-2111
US

V. Phone/Fax

Practice location:
  • Phone: 952-920-3844
  • Fax: 952-920-3008
Mailing address:
  • Phone: 952-920-3844
  • Fax: 952-920-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number9671
License Number StateMN

VIII. Authorized Official

Name: DR. THOMAS MAURICE KEANE JR.
Title or Position: OWNER/ORAL SURGEON
Credential: DDS
Phone: 952-920-3844