Provider Demographics
NPI:1295030203
Name:DEREK R. KAELIN, D.D.S, LLC
Entity Type:Organization
Organization Name:DEREK R. KAELIN, D.D.S, LLC
Other - Org Name:NORTHSIDE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:R
Authorized Official - Last Name:KAELIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-862-2468
Mailing Address - Street 1:2105 W KEARNEY ST STE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-1666
Mailing Address - Country:US
Mailing Address - Phone:417-862-2468
Mailing Address - Fax:417-863-6775
Practice Address - Street 1:2105 W KEARNEY ST STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-1666
Practice Address - Country:US
Practice Address - Phone:417-862-2468
Practice Address - Fax:417-863-6775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003017125261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental