Healthcare Provider Details

I. General information

NPI: 1578511572
Provider Name (Legal Business Name): BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 W SUPERIOR ST SUITE 720
DULUTH MN
55802-1701
US

IV. Provider business mailing address

324 W SUPERIOR ST SUITE 720
DULUTH MN
55802-1701
US

V. Phone/Fax

Practice location:
  • Phone: 218-727-8994
  • Fax: 218-727-8995
Mailing address:
  • Phone: 218-727-8994
  • Fax: 218-727-8995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateMN

VIII. Authorized Official

Name: MRS. JEAN DIANE SOUTHWORTH
Title or Position: BUSINESS ADMINISTRATOR
Credential:
Phone: 218-727-8994