Provider Demographics
NPI:1093261190
Name:GROUP HEALTH PLAN, INC.
Entity Type:Organization
Organization Name:GROUP HEALTH PLAN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP/ DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:GESKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-883-7577
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-5155
Mailing Address - Fax:952-883-5160
Practice Address - Street 1:8515 EAGLE POINT BLVD
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-8624
Practice Address - Country:US
Practice Address - Phone:651-523-9950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10265122300000X, 1223P0700X
MN118431223E0200X, 1223G0001X
MN113161223P0221X
MN100281223P0300X
MN113151223S0112X
MN98121223X0400X
MN12047125Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No125Q00000XDental ProvidersOral MedicinistGroup - Multi-Specialty