Healthcare Provider Details

I. General information

NPI: 1942072871
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGERY OF MINNESOTA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 19TH AVE SW
WILLMAR MN
56201-5005
US

IV. Provider business mailing address

15170 N FLORIDA AVE
TAMPA FL
33613-1229
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-1803
  • Fax:
Mailing address:
  • Phone: 813-755-9100
  • Fax:

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: MICHAEL BARBICK
Title or Position: OWNER
Credential: DMD MD
Phone: 813-755-9100