Provider Demographics
NPI:1558764597
Name:GROUP HEALTH PLAN, INC
Entity Type:Organization
Organization Name:GROUP HEALTH PLAN, INC
Other - Org Name:HEALTHPARTNERS PLYMOUTH DENTAL CLINIC
Other - Org Type:Doing Business As
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:952-883-5151
Mailing Address - Fax:
Practice Address - Street 1:4155 COUNTY RD 101 N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-2308
Practice Address - Country:US
Practice Address - Phone:952-977-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124651223G0001X
MN122451223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty