Provider Demographics
NPI:1275763674
Name:MAPLE STREET, PC
Entity Type:Organization
Organization Name:MAPLE STREET, PC
Other - Org Name:HOUSTON DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:EVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-896-2202
Mailing Address - Street 1:109 E MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MN
Mailing Address - Zip Code:55943-8449
Mailing Address - Country:US
Mailing Address - Phone:507-896-2202
Mailing Address - Fax:
Practice Address - Street 1:109 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MN
Practice Address - Zip Code:55943-8449
Practice Address - Country:US
Practice Address - Phone:507-896-2202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-20
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND112691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN459846600Medicaid