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General NPI Number Information
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NPI Number | 1285757864
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Entity Type | Organization
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Legal Business Name | MINNESOTA CRANIOFACIAL CENTER MIDWAY, P.A.
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Dates
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Enumeration Date | 04/09/2007
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Last Update Date | 09/26/2013
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Provider Practice Location Address
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Address Line | 2550 UNIVERSITY AVE W SUITE 143N
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City | SAINT PAUL
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State | MN
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Zip | 55114-1052
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Country | US
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Telephone | 651-642-1013
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Fax | 651-642-0947
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Provider Business Mailing Address
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Address Line | 2550 UNIVERSITY AVENUE WEST SUITE 143N
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City | SAINT PAUL
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State | MN
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Zip | 55114-1098
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Country | US
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Telephone | 651-642-1013
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Fax | 651-642-0947
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Authorized Official
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Title or Position | CEO OWNER
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Name | DR. ROY VERNON HAKALA
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Credential | D.D.S.
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Telephone | 651-642-1013
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D8171
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License Number State | MN
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