Organization
NORTHERN STAR ORAL AND MAXILLOFACIAL SURGERY PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JULIE A CHAVEZ DDS (OWNER)
(952) 465-0105
Entity
Organization
Contact information
Practice address
5100 GAMBLE DR, SUITE 125, ST LOUIS PARK, MN 55416-1585
(952) 465-0105
(952) 465-0106
Mailing address
5100 GAMBLE DR, SUITE 125, ST LOUIS PARK, MN 55416-1585
(952) 465-0105
(952) 465-0106
Taxonomy
Speciality
Code
Description
License number
State
261QS0112X
Oral and Maxillofacial Surgery Clinic/Center
Primary
D11399
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
187847
U CARE
MN
01
—
3AI37NO
BLUE CROSS BLUE SHIELD
MN
01
—
CO5268
MEDICARE PTAN
MN
01
—
DQ4459
MEDICARE RAILROAD PTAN
MN
Enumeration date
06/10/2009
Last updated
06/23/2014
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