Organization
MAPLE GROVE FAMILY DENTAL CLINIC, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. SUSAN M. LARSON (CLINIC ADMINISTRATOR)
(763) 420-4421
Entity
Organization
Contact information
Practice address
12000 ELM CREEK BLVD N, SUITE #220, MAPLE GROVE, MN 55369-7073
(763) 420-4421
(763) 420-5674
Mailing address
12000 ELM CREEK BLVD N, SUITE #220, MAPLE GROVE, MN 55369-7073
(763) 420-4421
(763) 420-5674
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
10067
MN
1223G0001X
General Practice Dentistry
9790
MN
1223G0001X
General Practice Dentistry
Primary
D11341
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10656
BLUECROSSBLUE SHIELD
MN
Enumeration date
10/23/2006
Last updated
08/22/2020
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