Organization
BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.
Active
Organization
BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JEAN DIANE SOUTHWORTH (BUSINESS ADMINISTRATOR)
(218) 727-8994
Entity
Organization
Contact information
Practice address
324 W SUPERIOR ST, SUITE 720, DULUTH, MN 55802-1701
(218) 727-8994
(218) 727-8995
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 (CLOQUET
MN
01
—
01630541
UNITED CONCORDIA (DULUTH)
MN
01
—
6B297JE
BLUE CROSS/BLUE SHIELD MN
MN
Enumeration date
05/04/2006
Last updated
08/22/2020
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