Healthcare Provider Details

I. General information

NPI: 1619049921
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGICAL CONSULTANTS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7373 FRANCE AVE S SUITE 602
EDINA MN
55435-4534
US

IV. Provider business mailing address

7373 FRANCE AVE S SUITE 602
EDINA MN
55435-4534
US

V. Phone/Fax

Practice location:
  • Phone: 952-835-5003
  • Fax:
Mailing address:
  • Phone: 952-835-5003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DEBI KECKHAFER
Title or Position: PRACTICE MANAGER
Credential: RN
Phone: 952-841-9658