Provider Demographics
NPI:1326290727
Name:BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.
Entity Type:Organization
Organization Name:BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGAER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:SOUTHWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-727-8994
Mailing Address - Street 1:324 W SUPERIOR ST
Mailing Address - Street 2:SUITE 720
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1701
Mailing Address - Country:US
Mailing Address - Phone:218-727-8994
Mailing Address - Fax:218-727-8995
Practice Address - Street 1:1616 CLOQUET AVE
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1948
Practice Address - Country:US
Practice Address - Phone:218-879-3761
Practice Address - Fax:218-879-6057
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN166644400Medicaid
MNDB2954OtherRAILROAD MEDICAL GROUP#
MN01630538OtherUNITED CONCORDIA (CLOUQET)
MNU12947OtherUPIN#
01630541OtherUNITED CONCORDIA (DULUTH)
MN6B297JEOtherBLUE CROSS/BLUE SHIELD MN
MNU12947OtherUPIN#