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11800 Aberdeen St Ne Ste 130 Blaine MN 55449-4813 | |
| (763) 757-2220 | |
| (763) 757-9204 |
| Full Name | |
|---|---|
| Speciality | Dentist - Oral And Maxillofacial Surgery |
| Location | 11800 Aberdeen St Ne Ste 130, Blaine, Minnesota |
| Authorized Official Name and Position | Kirby Charles Johnson (PRESIDENT) |
| Authorized Official Contact | 6127889246 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
550 County Road D Suite 12 New Brighton MN 55112 Ph: (651) 259-9902 | 11800 Aberdeen St Ne Ste 130 Blaine MN 55449-4813 Ph: (763) 757-2220 |
| NPI Number | 1467563510 |
|---|---|
| Provider Enumeration Date | 08/31/2006 |
| Last Update Date | 07/29/2014 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1467563510 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | (* (Not Available)) | Primary |
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