Healthcare Provider Details

I. General information

NPI: 1902099559
Provider Name (Legal Business Name): SOUTHEASTERN MINNESOTA ORAL & MAXILLOFACIAL SURGERY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 08/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 S SERVICE DR
RED WING MN
55066-1882
US

IV. Provider business mailing address

2835 S SERVICE DR
RED WING MN
55066-1882
US

V. Phone/Fax

Practice location:
  • Phone: 651-388-1515
  • Fax: 651-388-5912
Mailing address:
  • Phone: 651-388-1515
  • Fax: 651-388-5912

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. ROBERT A NUSTAD
Title or Position: VP, TREASURER
Credential: DDS, MS
Phone: 651-388-1515