Organization
BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.
Active
Parent organization
BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.
Organization subpart
Yes
Provider details
NPI number
Legal business name
BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.
Authorized official
MRS. JEAN DIANE SOUTHWORTH (BUSINESS MANAGAER)
(218) 727-8994
Entity
Organization
Contact information
Practice address
1616 CLOQUET AVE, CLOQUET, MN 55720-1948
(218) 879-3761
(218) 879-6057
Mailing address
324 W SUPERIOR ST, SUITE 720, DULUTH, MN 55802-1701
(218) 727-8994
(218) 727-8995
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
—
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01630538
UNITED CONCORDIA (CLOUQET)
MN
01
—
01630541
UNITED CONCORDIA (DULUTH)
—
05
—
166644400
—
MN
01
—
6B297JE
BLUE CROSS/BLUE SHIELD MN
MN
01
—
DB2954
RAILROAD MEDICAL GROUP#
MN
01
—
U12947
UPIN#
MN
Enumeration date
10/16/2008
Last updated
10/16/2008
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