MEDICARE: DENTAL GROUP NORTHLAND

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	2016018920	MO

General Provider Information

NPI Number	:	1255878070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL GROUP NORTHLAND

Provider Business Mailing Address
First Line	:	5950 N OAK TRFY
Second Line	:
City	:	GLADSTONE
State	:	MO
Zip	:	64118-5166
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5950 N OAK TRFY
Second Line	:
City	:	GLADSTONE
State	:	MO
Zip	:	64118-5166
Country	:	US
Telephone Number	:	816-436-5558
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	OLA SALMAN
Credential	:
Telephone Number	:	816-716-8224

Provider Enumeration Date	:	01/31/2017
Last Update Date	:	01/31/2017

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