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General NPI Number Information
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NPI Number | 1508058322
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Entity Type | Organization
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Legal Business Name | GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.
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Dates
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Enumeration Date | 08/15/2007
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Last Update Date | 10/20/2010
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Provider Practice Location Address
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Address Line | 2850 CURVE CREST BLVD SUITE 130
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City | STILLWATER
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State | MN
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Zip | 55082
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Country | US
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Telephone | 651-351-1010
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Fax | 651-351-9333
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Provider Business Mailing Address
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Address Line | 2850 CURVE CREST BLVD SUITE 130
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City | STILLWATER
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State | MN
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Zip | 55082
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Country | US
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Telephone | 651-351-1010
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Fax | 651-351-9333
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MRS. CONNIE LOUISE MILLER
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Credential |
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Telephone | 651-351-1010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 10762
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License Number State | MN
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