Healthcare Provider Details

I. General information

NPI: 1700975216
Provider Name (Legal Business Name): GROUP HEALTH PLAN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 CURVE CREST BLVD
STILLWATER MN
55082
US

IV. Provider business mailing address

1395 CURVE CREST BLVD
STILLWATER MN
55082
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-1966
  • Fax: 651-439-7555
Mailing address:
  • Phone: 651-439-1966
  • Fax: 651-439-7555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9652MN
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9652
License Number StateMN

VIII. Authorized Official

Name: DR. DAVID S GESKO
Title or Position: DENTAL DIV/SR VP
Credential: DDS
Phone: 952-883-7577