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Organization
GLEN LAKE FAMILY DENTISTRY P.L.L.C.
Active
Organization
GLEN LAKE FAMILY DENTISTRY P.L.L.C.
Active
Other names
NONE
Organization subpart
No
Provider details
NPI number
Authorized official
GREGORY ALAN OLSON D.D.S. (DENTIST)
(952) 938-6038
Entity
Organization
Contact information
Practice address
5509 EDEN PRAIRIE RD, MINNETONKA, MN 55345-5839
(952) 938-6038
(952) 935-9175
Mailing address
5509 EDEN PRAIRIE RD, MINNETONKA, MN 55345-5839
(952) 938-6038
(952) 935-9175
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D11282/D10240
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
674718300
STATE MEDICAL ASSISTANCE#
MN
Enumeration date
07/11/2006
Last updated
10/21/2009
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