Healthcare Provider Details

I. General information

NPI: 1982242061
Provider Name (Legal Business Name): MINNESOTA HEAD AND NECK SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 TROOP DR UNIT 202
SARTELL MN
56377-4637
US

IV. Provider business mailing address

2380 TROOP DR UNIT 202
SARTELL MN
56377-4637
US

V. Phone/Fax

Practice location:
  • Phone: 320-257-9555
  • Fax:
Mailing address:
  • Phone: 320-257-9555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DEEPAK KADEMANI
Title or Position: OWNER
Credential: DMD, MD
Phone: 320-257-9555