| None | |
|
5509 Eden Prairie Rd Minnetonka MN 55345-5839 | |
| (952) 938-6038 | |
| (952) 935-9175 |
| Full Name | None |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 5509 Eden Prairie Rd, Minnetonka, Minnesota |
| Authorized Official Name and Position | Gregory Alan Olson (DENTIST) |
| Authorized Official Contact | 9529386038 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| None 5509 Eden Prairie Rd Minnetonka MN 55345-5839 Ph: (952) 938-6038 | None 5509 Eden Prairie Rd Minnetonka MN 55345-5839 Ph: (952) 938-6038 |
| NPI Number | 1740215656 |
|---|---|
| Provider Enumeration Date | 07/11/2006 |
| Last Update Date | 10/21/2009 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1740215656 | NPI | - | NPPES |
| 674718300 | Other | MN | STATE MEDICAL ASSISTANCE# |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | D11282/D10240 (Minnesota) | Primary |
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