NPIMap

Organization Active NPI

Maple Grove Family Dental Clinic, PA

  • General Practice Dentistry
  • Maple Grove, MN
National Provider Identifier
1922181197
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
D11341 Issued in MN
Legal business name
MAPLE GROVE FAMILY DENTAL CLINIC, PA
Practice address
12000 Elm Creek Blvd N
Suite #220
Maple Grove, MN 55369-7073
Phone
(763) 420-4421
Fax
(763) 420-5674
NPI assigned
Oct 23, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Ms. Susan M. Larson
Title
Clinic Administrator
Phone
(763) 420-4421

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X 9790 MN
General Practice Dentistry 1223G0001X 10067 MN
General Practice Dentistry 1223G0001X D11341 MN Primary

Addresses

Primary practice location

12000 Elm Creek Blvd N
Suite #220
Maple Grove, MN 55369-7073

Mailing address

12000 Elm Creek Blvd N
Suite #220
Maple Grove, MN 55369-7073
Phone (763) 420-4421

Other identifiers 1

IdentifierTypeStateIssuer
10656OtherMNBLUECROSSBLUE SHIELD

National Provider Directory

National Provider Directory

Locations

12000 Elm Creek Blvd N
Ste 220
Maple Grove, MN 55369
Phone (763) 420-4421

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1161561600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1922181197",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12000 ELM CREEK BLVD N",
            "address_2": "SUITE #220",
            "city": "MAPLE GROVE",
            "state": "MN",
            "postal_code": "553697073",
            "telephone_number": "763-420-4421",
            "fax_number": "763-420-5674"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12000 ELM CREEK BLVD N",
            "address_2": "SUITE #220",
            "city": "MAPLE GROVE",
            "state": "MN",
            "postal_code": "553697073",
            "telephone_number": "763-420-4421",
            "fax_number": "763-420-5674"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAPLE GROVE FAMILY DENTAL CLINIC, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-23",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "LARSON",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "M.",
        "authorized_official_title_or_position": "CLINIC ADMINISTRATOR",
        "authorized_official_telephone_number": "763-420-4421",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "9790",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "10067",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "D11341",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUECROSSBLUE SHIELD",
            "identifier": "10656",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Maple Grove, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; 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.