=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023259546
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN DENTAL SPECIALISTS, DR. STEVEN W GAJDA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2009
-----------------------------------------------------
Last Update Date | 03/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2040 HUBBARD ROAD
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-428-7290
-----------------------------------------------------
Fax | 440-428-0911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2040 HUBBARD ROAD
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-428-7290
-----------------------------------------------------
Fax | 440-428-0911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STEVEN W GAJDA
-----------------------------------------------------
Credential | DDS, MSD
-----------------------------------------------------
Telephone | 440-428-7290
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 30-022716
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------