Provider Demographics
NPI:1922401793
Name:NORTHSIDE DENTAL L.L.C.
Entity Type:Organization
Organization Name:NORTHSIDE DENTAL L.L.C.
Other - Org Name:NORTHSIDE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:KAELIN,
Authorized Official - Last Name:DDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-862-2468
Mailing Address - Street 1:2105 W KEARNEY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-1652
Mailing Address - Country:US
Mailing Address - Phone:417-862-2468
Mailing Address - Fax:417-863-6775
Practice Address - Street 1:2105 W KEARNEY ST
Practice Address - Street 2:SUITE A
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-1652
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:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003017125261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental