Provider Demographics
NPI:1235291816
Name:NORTHLAND FAMILY DENTISTRY
Entity type:Organization
Organization Name:NORTHLAND FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARYCLARE
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-262-5536
Mailing Address - Street 1:2011 3RD AVE E
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-1731
Mailing Address - Country:US
Mailing Address - Phone:218-262-5536
Mailing Address - Fax:218-263-8554
Practice Address - Street 1:2011 3RD AVE E
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-1731
Practice Address - Country:US
Practice Address - Phone:218-262-5536
Practice Address - Fax:218-263-8554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN71671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty