Healthcare Provider Details

I. General information

NPI: 1679668529
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGICAL ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 SE 1ST ST
GRAND RAPIDS MN
55744-3681
US

IV. Provider business mailing address

303 SE 1ST ST
GRAND RAPIDS MN
55744-3681
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-0349
  • Fax: 218-326-5005
Mailing address:
  • Phone: 218-326-0349
  • Fax: 218-326-5005

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: KATHERINE ANNE LAFLEUR
Title or Position: PRACTICE ADMINISTRATOR
Credential: MBA
Phone: 218-722-1854