MEDICARE: BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)		MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01630538	OTHER	MN	UNITED CONCORDIA (CLOQUET
2	01630541	OTHER	MN	UNITED CONCORDIA (DULUTH)
3	6B297JE	OTHER	MN	BLUE CROSS/BLUE SHIELD MN

General Provider Information

NPI Number	:	1578511572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.

Provider Business Mailing Address
First Line	:	324 W SUPERIOR ST
Second Line	:	SUITE 720
City	:	DULUTH
State	:	MN
Zip	:	55802-1701
Country	:	US
Telephone Number	:	218-727-8994
Fax Number	:	218-727-8995

Provider Business Practice Location Address
First Line	:	324 W SUPERIOR ST
Second Line	:	SUITE 720
City	:	DULUTH
State	:	MN
Zip	:	55802-1701
Country	:	US
Telephone Number	:	218-727-8994
Fax Number	:	218-727-8995

Authorized Official
Title or Position	:	BUSINESS ADMINISTRATOR
Name	:	MRS. JEAN DIANE SOUTHWORTH
Credential	:
Telephone Number	:	218-727-8994

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	08/22/2020

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Directions to “BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A. ” Practice Location

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