Basic Information
| Provider Information | |||||||||
| NPI: | 1407851694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEXTER | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 OSBORNE RD NE | ||||||||
| Address2: | SUITE 255 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554322774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632362500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 OSBORNE RD NE | ||||||||
| Address2: | SUITE 255 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554322774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632362500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 49295 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34413400 | 05 | WI | MEDICAID | 495L6FU | 01 | MN | BCBS OF MN | OTHER | 180463 | 01 | MN | UCARE MN | OTHER | 6610246 | 01 | MN | MEDICA URGENT CARE | OTHER | 0125449 | 01 | MN | MEDICA | OTHER | 1035384 | 01 | MN | PREFERRED ONE | OTHER | 762614200 | 05 | MN | MEDICAID | HP39823 | 01 | MN | HEALTHPARTNERS | OTHER |