Provider Demographics
NPI:1164877395
Name:NORTHERN DENTAL GENERAL AND COSMETIC DENTISTRY LLC
Entity Type:Organization
Organization Name:NORTHERN DENTAL GENERAL AND COSMETIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-431-5666
Mailing Address - Street 1:5651 NAPLES BLVD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-2023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5651 NAPLES BLVD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-2023
Practice Address - Country:US
Practice Address - Phone:239-431-5666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20711122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016807000Medicaid