MEDICARE: ST. PAUL ORAL SURGERY, P.A.

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)	7933	MN

General Provider Information

NPI Number	:	1548218910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. PAUL ORAL SURGERY, P.A.

Provider Business Mailing Address
First Line	:	710 19TH AVE N
Second Line	:	SUITE 300
City	:	SOUTH ST PAUL
State	:	MN
Zip	:	55075-1359
Country	:	US
Telephone Number	:	651-451-1873
Fax Number	:	651-451-8010

Provider Business Practice Location Address
First Line	:	710 19TH AVE N
Second Line	:	SUITE 300
City	:	SOUTH ST PAUL
State	:	MN
Zip	:	55075-1359
Country	:	US
Telephone Number	:	651-451-1873
Fax Number	:	651-451-8010

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DALE VICTOR OLSON
Credential	:	D.D.S.
Telephone Number	:	651-451-1873

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	08/22/2020

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Directions to “ST. PAUL ORAL SURGERY, P.A. ” Practice Location

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