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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