=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043960776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHLAND DENTAL PARTNERS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2022
-----------------------------------------------------
Last Update Date | 03/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2690 SNELLING AVE N STE 200
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113-1799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-633-1834
-----------------------------------------------------
Fax | 651-633-0995
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2690 SNELLING AVE N STE 200
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113-1799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-633-1834
-----------------------------------------------------
Fax | 651-633-0995
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | CELIA HAYES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------