Healthcare Provider Details

I. General information

NPI: 1598865651
Provider Name (Legal Business Name): FAMILY ORAL SURGERY SPECIALISTS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/10/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 LYNDALE AVE S STE 230
RICHFIELD MN
55423-2479
US

IV. Provider business mailing address

6601 LYNDALE AVE S STE 230
RICHFIELD MN
55423-2479
US

V. Phone/Fax

Practice location:
  • Phone: 612-861-9123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: BELINDA HUERTA
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-2100