MEDICARE: GLEN LAKE DENTAL ASSOCIATES, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D9306	MN

General Provider Information

NPI Number	:	1003062084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLEN LAKE DENTAL ASSOCIATES, P.A.

Provider Business Mailing Address
First Line	:	14418 EXCELSIOR BLVD
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-5820
Country	:	US
Telephone Number	:	952-935-5212
Fax Number	:	952-935-1391

Provider Business Practice Location Address
First Line	:	14418 EXCELSIOR BLVD
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-5820
Country	:	US
Telephone Number	:	952-935-5212
Fax Number	:	952-935-1391

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KENT CASSIDY
Credential	:	D.D.S.
Telephone Number	:	952-935-5212

Provider Enumeration Date	:	08/11/2008
Last Update Date	:	08/11/2008

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