Provider Demographics
NPI:1336430149
Name:GROUP HEALTH PLAN, INC
Entity Type:Organization
Organization Name:GROUP HEALTH PLAN, INC
Other - Org Name:THREE RIVERS ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP/DENTAL DIR.
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 1:2150 THIRD AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2206
Mailing Address - Country:US
Mailing Address - Phone:763-421-9292
Mailing Address - Fax:763-421-7559
Practice Address - Street 1:2150 THIRD AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2206
Practice Address - Country:US
Practice Address - Phone:763-421-9292
Practice Address - Fax:763-421-7559
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GROUP HEALTH PLAN, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-27
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND122451223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty