Healthcare Provider Details

I. General information

NPI: 1497404818
Provider Name (Legal Business Name): FAMILY ORAL SURGERY SPECIALISTS, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15785 95TH AVE N
MAPLE GROVE MN
55369-4404
US

IV. Provider business mailing address

15785 95TH AVE N
MAPLE GROVE MN
55369-4404
US

V. Phone/Fax

Practice location:
  • Phone: 763-233-4141
  • Fax: 763-420-3158
Mailing address:
  • Phone: 763-233-4141
  • Fax: 763-420-3158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CELIA HAYES
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-2100