Healthcare Provider Details

I. General information

NPI: 1194968750
Provider Name (Legal Business Name): GERALD EDWARD MAHER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FIRST AVE SW
GLENWOOD MN
56334-0174
US

IV. Provider business mailing address

BOX 174
GLENWOOD MN
56334-0174
US

V. Phone/Fax

Practice location:
  • Phone: 320-634-4543
  • Fax: 320-634-4544
Mailing address:
  • Phone: 320-634-4543
  • Fax: 320-634-4544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7325
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: