MEDICARE: MAPLE STREET, PC

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	D11269	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275763674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAPLE STREET, PC

Provider Business Mailing Address
First Line	:	109 E MAPLE ST
Second Line	:
City	:	HOUSTON
State	:	MN
Zip	:	55943-8449
Country	:	US
Telephone Number	:	507-896-2202
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 E MAPLE ST
Second Line	:
City	:	HOUSTON
State	:	MN
Zip	:	55943-8449
Country	:	US
Telephone Number	:	507-896-2202
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN W EVENSON
Credential	:	D.D.S.
Telephone Number	:	507-896-2202

Provider Enumeration Date	:	07/20/2009
Last Update Date	:	07/20/2009

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Directions to “MAPLE STREET, PC ” Practice Location

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