Healthcare Provider Details

I. General information

NPI: 1699901140
Provider Name (Legal Business Name): NORTHERN STAR ORAL AND MAXILLOFACIAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 GAMBLE DR SUITE 125
ST LOUIS PARK MN
55416-1585
US

IV. Provider business mailing address

5100 GAMBLE DR SUITE 125
ST LOUIS PARK MN
55416-1585
US

V. Phone/Fax

Practice location:
  • Phone: 952-465-0105
  • Fax: 952-465-0106
Mailing address:
  • Phone: 952-465-0105
  • Fax: 952-465-0106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberD11399
License Number StateMN

VIII. Authorized Official

Name: DR. JULIE A CHAVEZ
Title or Position: OWNER
Credential: DDS
Phone: 952-465-0105