MEDICARE: NORTHLAND DENTAL PARTNERS, PLLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1619625043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHLAND DENTAL PARTNERS, PLLC

Provider Business Mailing Address
First Line	:	1965 CLIFF LAKE RD STE 102
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-2591
Country	:	US
Telephone Number	:	651-452-4828
Fax Number	:	651-681-0856

Provider Business Practice Location Address
First Line	:	1965 CLIFF LAKE RD STE 102
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-2591
Country	:	US
Telephone Number	:	651-452-4828
Fax Number	:	651-681-0856

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	CELIA HAYES
Credential	:
Telephone Number	:	217-540-2100

Provider Enumeration Date	:	03/15/2022
Last Update Date	:	03/15/2022

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