NPIMap

Organization Active NPI

Great Lakes Oral & Maxillofacial Surgery, P.a.

  • Oral and Maxillofacial Surgery (Dentist)
  • Stillwater, MN
National Provider Identifier
1508058322
Registry record updated Oct 20, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X
License
10762 Issued in MN
Legal business name
GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.
Practice address
2850 Curve Crest Blvd
Suite 130
Stillwater, MN 55082
Phone
(651) 351-1010
Fax
(651) 351-9333
NPI assigned
Aug 15, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 20, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Connie Louise Miller
Title
Practice Manager
Phone
(651) 351-1010

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery (Dentist)Group: 193400000X SINGLE SPECIALTY GROUP 1223S0112X 10762 MN Primary

Addresses

Primary practice location

2850 Curve Crest Blvd
Suite 130
Stillwater, MN 55082

Mailing address

2850 Curve Crest Blvd
Suite 130
Stillwater, MN 55082
Phone (651) 351-1010

Other identifiers 4

IdentifierTypeStateIssuer
33714200OtherWIMEDICAL ASSISTANCE
CC02769MedicaidMN
616822100OtherMNMEDICAL ASSISTANCE
88A90BROtherMNBLUE CROSS BLUE SHIELD

Other names 1

  • Richard W Brunton PA Former legal business name

National Provider Directory

National Provider Directory
Tax ID family
Great Lakes Oral Maxillofacial Surgery PA3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

2850 Curve Crest Blvd W
Ste 130
Stillwater, MN 55082
Phone (651) 233-2140

227 Meridian Dr
New Richmond, WI 54017
Phone (715) 381-7070

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1187136000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1287532800000",
    "number": "1508058322",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2850 CURVE CREST BLVD",
            "address_2": "SUITE 130",
            "city": "STILLWATER",
            "state": "MN",
            "postal_code": "55082",
            "telephone_number": "651-351-1010",
            "fax_number": "651-351-9333"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2850 CURVE CREST BLVD",
            "address_2": "SUITE 130",
            "city": "STILLWATER",
            "state": "MN",
            "postal_code": "55082",
            "telephone_number": "651-351-1010",
            "fax_number": "651-351-9333"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-08-15",
        "last_updated": "2010-10-20",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "CONNIE",
        "authorized_official_middle_name": "LOUISE",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "651-351-1010",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "MN",
            "license": "10762",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL ASSISTANCE",
            "identifier": "33714200",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "CC02769",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL ASSISTANCE",
            "identifier": "616822100",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "88A90BR",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Richard W Brunton PA",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Stillwater, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 20, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.