NPIMap

Organization Active NPI

Glen Lake Family Dentistry P.L.L.C.

  • General Practice Dentistry
  • Minnetonka, MN
National Provider Identifier
1740215656
Registry record updated Oct 21, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
D11282/D10240 Issued in MN
Legal business name
GLEN LAKE FAMILY DENTISTRY P.L.L.C.
Practice address
5509 Eden Prairie Rd
Minnetonka, MN 55345-5839
Phone
(952) 938-6038
Fax
(952) 935-9175
NPI assigned
Jul 11, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 21, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Gregory Alan Olson, D.D.S.NPI 1184659435
Title
Dentist
Phone
(952) 938-6038

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X D11282/D10240 MN Primary

Addresses

Primary practice location

5509 Eden Prairie Rd
Minnetonka, MN 55345-5839

Mailing address

5509 Eden Prairie Rd
Minnetonka, MN 55345-5839
Phone (952) 938-6038

Other identifiers 1

IdentifierTypeStateIssuer
674718300OtherMNSTATE MEDICAL ASSISTANCE#

Other names 1

  • NONE Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152576000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1256083200000",
    "number": "1740215656",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5509 EDEN PRAIRIE RD",
            "city": "MINNETONKA",
            "state": "MN",
            "postal_code": "553455839",
            "telephone_number": "952-938-6038",
            "fax_number": "952-935-9175"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5509 EDEN PRAIRIE RD",
            "city": "MINNETONKA",
            "state": "MN",
            "postal_code": "553455839",
            "telephone_number": "952-938-6038",
            "fax_number": "952-935-9175"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GLEN LAKE FAMILY DENTISTRY P.L.L.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-11",
        "last_updated": "2009-10-21",
        "status": "A",
        "authorized_official_last_name": "OLSON",
        "authorized_official_first_name": "GREGORY",
        "authorized_official_middle_name": "ALAN",
        "authorized_official_title_or_position": "DENTIST",
        "authorized_official_telephone_number": "952-938-6038",
        "authorized_official_credential": "D.D.S."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "D11282/D10240",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE MEDICAL ASSISTANCE#",
            "identifier": "674718300",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "NONE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Minnetonka, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 21, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.