Provider Demographics
NPI:1649672569
Name:NORTHLAND DENTAL
Entity type:Organization
Organization Name:NORTHLAND DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:MANCIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:816-436-2760
Mailing Address - Street 1:7229 N OAK TRFY
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118-1852
Mailing Address - Country:US
Mailing Address - Phone:816-436-0354
Mailing Address - Fax:816-468-7034
Practice Address - Street 1:7229 N OAK TRFY
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-1852
Practice Address - Country:US
Practice Address - Phone:816-436-0354
Practice Address - Fax:816-468-7034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014031160122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty