Provider Demographics
NPI:1619619129
Name:NORTHLAND DENTAL PARTNERS, PLLC
Entity Type:Organization
Organization Name:NORTHLAND DENTAL PARTNERS, PLLC
Other - Org Name:CENTRAL AVENUE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:12371 ULYSSES ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-3910
Mailing Address - Country:US
Mailing Address - Phone:763-203-6100
Mailing Address - Fax:
Practice Address - Street 1:12371 ULYSSES ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3910
Practice Address - Country:US
Practice Address - Phone:763-203-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHLAND DENTAL PARTNERS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-13
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty