Healthcare Provider Details

I. General information

NPI: 1497814032
Provider Name (Legal Business Name): MOMENTA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 VILLAGE CENTER DR STE 170
NORTH OAKS MN
55127-3025
US

IV. Provider business mailing address

700 VILLAGE CENTER DR STE 170
NORTH OAKS MN
55127-3025
US

V. Phone/Fax

Practice location:
  • Phone: 651-482-0065
  • Fax: 651-482-6144
Mailing address:
  • Phone: 651-482-0065
  • Fax: 651-482-6144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. KARL H ANDREASEN
Title or Position: PRESIDENT
Credential: DDS
Phone: 651-482-0065