NPIMap

Organization Active NPI

Centrasota Oral & Maxillofacial Surgeons, P.a.

  • Oral and Maxillofacial Surgery (Dentist)
  • Saint Cloud, MN
National Provider Identifier
1598710477
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X
Legal business name
CENTRASOTA ORAL & MAXILLOFACIAL SURGEONS, P.A.
Practice address
3950 Veterans Dr
Suite 100
Saint Cloud, MN 56303-3410
Phone
(320) 252-3611
Fax
(320) 252-7574
NPI assigned
May 22, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Robert J Keck, D.D.S., M.S.NPI 1902843683
Title
President
Phone
(320) 252-3611

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

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

Addresses

Primary practice location

3950 Veterans Dr
Suite 100
Saint Cloud, MN 56303-3410

Mailing address

3950 Veterans Dr
Suite 100
Saint Cloud, MN 56303-3410
Phone (320) 252-3611

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060110000046 MN Part B Supplier - Clinic/Group Practice 7315969326 Receives reassigned benefits from 7 practitioners
Practice locations: Alexandria, MN; Hutchinson, MN; Monticello, MN; Saint Cloud, MN; Sartell, MN

National Provider Directory

National Provider Directory

Locations

2633 Jefferson St
Ste 602
Alexandria, MN 56308
Phone (320) 763-5117

1015 Highway 15 S
Hutchinson, MN 55350
Phone (320) 252-3611

3880 Deegan Ct
Ste 100
Monticello, MN 55362
Phone (320) 252-3611

9381 Cedar St
Monticello, MN 55362
Phone (763) 295-2222

106 S Rum River Dr
Princeton, MN 55371
Phone (320) 252-3611

531 Pine Cone Rd
Sartell, MN 56377
Phone (320) 252-3611

Practitioners & affiliated clinicians

Practitioners 11

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": "1148256000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1598710477",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3950 VETERANS DR",
            "address_2": "SUITE 100",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563033410",
            "telephone_number": "320-252-3611",
            "fax_number": "320-252-7574"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3950 VETERANS DR",
            "address_2": "SUITE 100",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563033410",
            "telephone_number": "320-252-3611",
            "fax_number": "320-252-7574"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRASOTA ORAL & MAXILLOFACIAL SURGEONS, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-22",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "KECK",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "320-252-3611",
        "authorized_official_credential": "D.D.S., M.S."
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Cloud, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.