MEDICARE: DAKOTA VALLEY ORAL AND MAXILLOFACIAL SURGERY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6B354SE	OTHER	MN	BCBS MN CLINIC NUMBER

General Provider Information

NPI Number	:	1366568206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAKOTA VALLEY ORAL AND MAXILLOFACIAL SURGERY, PLLC

Provider Business Mailing Address
First Line	:	2130 CLIFF RD
Second Line	:	SUITE 100
City	:	SAINT PAUL
State	:	MN
Zip	:	55122-2485
Country	:	US
Telephone Number	:	651-452-6933
Fax Number	:

Provider Business Practice Location Address
First Line	:	2130 CLIFF RD
Second Line	:	SUITE 100
City	:	SAINT PAUL
State	:	MN
Zip	:	55122-2485
Country	:	US
Telephone Number	:	651-452-6933
Fax Number	:

Authorized Official
Title or Position	:	CLINIC MANAGER
Name	:	MICHELLE HARTMANN
Credential	:
Telephone Number	:	651-905-4834

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/06/2020

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