Healthcare Provider Details

I. General information

NPI: 1164763629
Provider Name (Legal Business Name): REGENTS OF THE UNIVERSITY OF MINNESOTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2013
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 DELAWARE ST SE 7TH FLOOR MOOS TOWER
MINNEAPOLIS MN
55455-0357
US

IV. Provider business mailing address

515 DELAWARE ST SE 7-314 MOOS TOWER
MINNEAPOLIS MN
55455-0357
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-6529
  • Fax:
Mailing address:
  • Phone: 612-626-6529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY CARL ANDERSON
Title or Position: DEAN, UOFMN SCHOOL OF DENTISTRY
Credential: DDS
Phone: 612-624-4681