Healthcare Provider Details

I. General information

NPI: 1699272427
Provider Name (Legal Business Name): GROUP HEALTH PLAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 EXCELSIOR BLVD
ST LOUIS PARK MN
55416-2935
US

IV. Provider business mailing address

8170 33RD AVE S
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-853-9120
  • Fax:
Mailing address:
  • Phone: 952-883-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code125K00000X
TaxonomyAdvanced Practice Dental Therapist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code125Q00000X
TaxonomyOral Medicine Dentistry
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DAVID ALAN DZIUK
Title or Position: SENIOR VP
Credential:
Phone: 952-883-6535