MEDICARE: THOMAS JASON NOMELAND D.D.S.

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	122300000X	Dentist	D11041	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1415467	OTHER	MN	UNITED CONCORDIA

General Provider Information

NPI Number	:	1174628622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS JASON NOMELAND D.D.S.

Provider Business Mailing Address
First Line	:	412 HERITAGE PL
Second Line	:
City	:	FARIBAULT
State	:	MN
Zip	:	55021-5248
Country	:	US
Telephone Number	:	507-334-7595
Fax Number	:

Provider Business Practice Location Address
First Line	:	412 HERITAGE PL
Second Line	:
City	:	FARIBAULT
State	:	MN
Zip	:	55021-5248
Country	:	US
Telephone Number	:	507-334-7595
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	07/08/2007

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