Healthcare Provider Details

I. General information

NPI: 1285768812
Provider Name (Legal Business Name): CRANIOFACIAL IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6545 FRANCE AVE S STE C61
EDINA MN
55435-2157
US

IV. Provider business mailing address

6545 FRANCE AVE S STE C61
EDINA MN
55435-2157
US

V. Phone/Fax

Practice location:
  • Phone: 952-926-1626
  • Fax:
Mailing address:
  • Phone: 952-926-1626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SCOTT R BOWLBY
Title or Position: GENERAL PARTNER
Credential:
Phone: 952-926-1626