Provider Demographics
NPI:1972873156
Name:NORTHLAND DENTAL LTD.
Entity Type:Organization
Organization Name:NORTHLAND DENTAL LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-236-7076
Mailing Address - Street 1:2121 HIGHWAY 10 E
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-2559
Mailing Address - Country:US
Mailing Address - Phone:218-236-7076
Mailing Address - Fax:218-236-4999
Practice Address - Street 1:2121 HIGHWAY 10 E
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-2559
Practice Address - Country:US
Practice Address - Phone:218-236-7076
Practice Address - Fax:218-236-4999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN 9657261QD0000X
MND12404261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental