Healthcare Provider Details

I. General information

NPI: 1649136003
Provider Name (Legal Business Name): NORTHSIDE FAMILY DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2025
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5898 N MAIN ST STE 109
JOPLIN MO
64801-9103
US

IV. Provider business mailing address

5898 N MAIN ST STE 109
JOPLIN MO
64801-9103
US

V. Phone/Fax

Practice location:
  • Phone: 417-208-9842
  • Fax: 417-208-9843
Mailing address:
  • Phone: 417-208-9842
  • Fax: 417-208-9843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDREW BYRNE
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 417-758-9665