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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