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General NPI Number Information
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NPI Number | 1003062084
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Entity Type | Organization
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Legal Business Name | GLEN LAKE DENTAL ASSOCIATES, P.A.
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Dates
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Enumeration Date | 08/11/2008
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Last Update Date | 08/11/2008
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Provider Practice Location Address
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Address Line | 14418 EXCELSIOR BLVD
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City | MINNETONKA
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State | MN
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Zip | 55345-5820
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Country | US
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Telephone | 952-935-5212
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Fax | 952-935-1391
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Provider Business Mailing Address
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Address Line | 14418 EXCELSIOR BLVD
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City | MINNETONKA
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State | MN
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Zip | 55345-5820
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Country | US
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Telephone | 952-935-5212
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Fax | 952-935-1391
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Authorized Official
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Title or Position | PRESIDENT
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Name | KENT CASSIDY
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Credential | D.D.S.
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Telephone | 952-935-5212
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D9306
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License Number State | MN
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