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General NPI Number Information
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NPI Number | 1689723686
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Entity Type | Organization
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Legal Business Name | INSTITUTE OF FACIAL SURGERY ST PAUL
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Dates
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Enumeration Date | 01/09/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1774 COPE AVE E SUITE 140
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City | MAPLEWOOD
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State | MN
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Zip | 55109-2662
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Country | US
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Telephone | 651-774-9611
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Fax | 651-748-3704
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Provider Business Mailing Address
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Address Line | 1774 COPE AVE E SUITE 140
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City | MAPLEWOOD
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State | MN
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Zip | 55109-2662
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Country | US
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Telephone | 651-774-9611
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Fax | 651-748-3704
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JERRY KENT BRUNSOMAN
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Credential | D.D.S., M.S.
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Telephone | 651-774-9611
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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 |
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License Number State |
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