Provider Demographics
NPI:1679732119
Name:MAXILLOFACIAL IMAGING LLC
Entity type:Organization
Organization Name:MAXILLOFACIAL IMAGING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:763-420-0070
Mailing Address - Street 1:13998 MAPLE KNOLL WAY
Mailing Address - Street 2:MAPLE GROVE PROFESSIONAL BLD SUITE LL105
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7004
Mailing Address - Country:US
Mailing Address - Phone:763-420-0070
Mailing Address - Fax:
Practice Address - Street 1:13998 MAPLE KNOLL WAY
Practice Address - Street 2:MAPLE GROVE PROFESSIONAL BLD SUITE LL105
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7004
Practice Address - Country:US
Practice Address - Phone:763-420-0070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology