Provider Demographics
NPI:1700975216
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:DENTAL DIV/SR VP
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 1:1395 CURVE CREST BLVD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082
Mailing Address - Country:US
Mailing Address - Phone:651-439-1966
Mailing Address - Fax:651-439-7555
Practice Address - Street 1:1395 CURVE CREST BLVD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-439-1966
Practice Address - Fax:651-439-7555
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GROUP HEALTH PLAN, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-12
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9652MN1223X0400X
MN96521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty