MEDICARE: NOMELAND DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D11041	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1415467	OTHER	MN	UNITED CONCORDIA

General Provider Information

NPI Number	:	1184847568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOMELAND DENTAL LLC

Provider Business Mailing Address
First Line	:	412 HERITAGE PL
Second Line	:
City	:	FARIBAULT
State	:	MN
Zip	:	55021-5248
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	412 HERITAGE PL
Second Line	:
City	:	FARIBAULT
State	:	MN
Zip	:	55021-5248
Country	:	US
Telephone Number	:	507-334-7595
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. THAMAS JASON NOMELAND
Credential	:	D.D.S.
Telephone Number	:	507-334-7595

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	08/22/2020

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