=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043513732
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHLAND FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2010
-----------------------------------------------------
Last Update Date | 12/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24179 TOMBALL PKWY SUITE B
-----------------------------------------------------
City | TOMBALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77375-8298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-377-6788
-----------------------------------------------------
Fax | 281-971-3948
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24179 TOMBALL PKWY SUITE B
-----------------------------------------------------
City | TOMBALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77375-8298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-377-6788
-----------------------------------------------------
Fax | 281-971-3948
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. BRYANT DEON CONLEY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 281-377-6788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 19059
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------