Provider Demographics
NPI:1902099559
Name:SOUTHEASTERN MINNESOTA ORAL & MAXILLOFACIAL SURGERY ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHEASTERN MINNESOTA ORAL & MAXILLOFACIAL SURGERY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:NUSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:651-388-1515
Mailing Address - Street 1:2835 S SERVICE DR
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-1882
Mailing Address - Country:US
Mailing Address - Phone:651-388-1515
Mailing Address - Fax:651-388-5912
Practice Address - Street 1:2835 S SERVICE DR
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-1882
Practice Address - Country:US
Practice Address - Phone:651-388-1515
Practice Address - Fax:651-388-5912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery