Provider Demographics
NPI:1740215656
Name:GLEN LAKE FAMILY DENTISTRY P.L.L.C.
Entity Type:Organization
Organization Name:GLEN LAKE FAMILY DENTISTRY P.L.L.C.
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-938-6038
Mailing Address - Street 1:5509 EDEN PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-5839
Mailing Address - Country:US
Mailing Address - Phone:952-938-6038
Mailing Address - Fax:952-935-9175
Practice Address - Street 1:5509 EDEN PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-5839
Practice Address - Country:US
Practice Address - Phone:952-938-6038
Practice Address - Fax:952-935-9175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11282/D102401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN674718300OtherSTATE MEDICAL ASSISTANCE#