Provider Demographics
NPI:1972242600
Name:NORTHERN, MOLLIE (DDS)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:NORTHERN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 OLD HIGHWAY 63 S
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6078
Mailing Address - Country:US
Mailing Address - Phone:573-449-0749
Mailing Address - Fax:
Practice Address - Street 1:1310 OLD HIGHWAY 63 S
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6078
Practice Address - Country:US
Practice Address - Phone:573-449-0749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220192971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice