Healthcare Provider Details

I. General information

NPI: 1003983701
Provider Name (Legal Business Name): MIDWEST ORAL & MAXILLOFACIAL SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13875 HWY 13 FRONTAGE RD STE 50
SAVAGE MN
55378
US

IV. Provider business mailing address

13875 HWY 13 FRONTAGE RD STE 50
SAVAGE MN
55378
US

V. Phone/Fax

Practice location:
  • Phone: 952-226-7940
  • Fax: 952-226-7949
Mailing address:
  • Phone: 952-226-7940
  • Fax: 952-226-7949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: GREGORY WARREN HUELER
Title or Position: PRESIDENT
Credential: DDS
Phone: 952-226-7940