Healthcare Provider Details

I. General information

NPI: 1922401793
Provider Name (Legal Business Name): NORTHSIDE DENTAL L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 W KEARNEY ST SUITE A
SPRINGFIELD MO
65803-1652
US

IV. Provider business mailing address

2105 W KEARNEY ST SUITE A
SPRINGFIELD MO
65803-1652
US

V. Phone/Fax

Practice location:
  • Phone: 417-862-2468
  • Fax: 417-863-6775
Mailing address:
  • Phone: 417-862-2468
  • Fax: 417-863-6775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2003017125
License Number StateMO

VIII. Authorized Official

Name: DR. DEREK KAELIN, DDS
Title or Position: OWNER/DENTIST
Credential: D.D.S
Phone: 417-862-2468