Healthcare Provider Details

I. General information

NPI: 1376818583
Provider Name (Legal Business Name): NORTHERN STAR DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 MAPLE ST
DANVERS MA
01923-2851
US

IV. Provider business mailing address

37 MAPLE ST
DANVERS MA
01923-2851
US

V. Phone/Fax

Practice location:
  • Phone: 978-750-9999
  • Fax:
Mailing address:
  • Phone: 978-750-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN22094
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN1855540
License Number StateMA

VIII. Authorized Official

Name: DR. MARCIN JARMOC
Title or Position: VICE PRESIDENT
Credential: DMD
Phone: 617-331-9544