MEDICARE: BLUESTONE DENTAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D12242	MN

General Provider Information

NPI Number	:	1801260187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUESTONE DENTAL PLLC

Provider Business Mailing Address
First Line	:	906 WOODLAND AVENUE
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55812-1113
Country	:	US
Telephone Number	:	218-606-1040
Fax Number	:

Provider Business Practice Location Address
First Line	:	906 WOODLAND AVENUE
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55812-1113
Country	:	US
Telephone Number	:	218-606-1040
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	WHITNEY CHRISTINE HUSTAD DAVIDSON
Credential	:	DDS
Telephone Number	:	218-606-1040

Provider Enumeration Date	:	11/24/2015
Last Update Date	:	11/24/2015

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