Healthcare Provider Details

I. General information

NPI: 1275892218
Provider Name (Legal Business Name): EDINA ORAL AND MAXILLOFACIAL SURGERY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6545 FRANCE AVE S SUITE 690
EDINA MN
55435-2131
US

IV. Provider business mailing address

6545 FRANCE AVE S SUITE 690
EDINA MN
55435-2131
US

V. Phone/Fax

Practice location:
  • Phone: 952-925-2525
  • Fax: 952-925-2529
Mailing address:
  • Phone: 952-925-2525
  • Fax: 952-925-2529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD11128
License Number StateMN

VIII. Authorized Official

Name: PAUL C TOMPACH
Title or Position: OWNER/DOCTOR
Credential:
Phone: 952-925-2525