Provider Demographics
NPI:1922181197
Name:MAPLE GROVE FAMILY DENTAL CLINIC, PA
Entity Type:Organization
Organization Name:MAPLE GROVE FAMILY DENTAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-420-4421
Mailing Address - Street 1:12000 ELM CREEK BLVD N
Mailing Address - Street 2:SUITE #220
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7073
Mailing Address - Country:US
Mailing Address - Phone:763-420-4421
Mailing Address - Fax:763-420-5674
Practice Address - Street 1:12000 ELM CREEK BLVD N
Practice Address - Street 2:SUITE #220
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7073
Practice Address - Country:US
Practice Address - Phone:763-420-4421
Practice Address - Fax:763-420-5674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN97901223G0001X
MN100671223G0001X
MND113411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10656OtherBLUECROSSBLUE SHIELD