# NORTHSIDE DENTAL L.L.C.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Northside Dental Clinic
- **Organization subpart:** No

## Provider details

- **NPI number:** 1922401793
- **Authorized official:** DR. DEREK KAELIN, DDS D.D.S (OWNER/DENTIST)
- **Authorized official phone:** (417) 862-2468

## Contact information

- **Practice address:** 2105 W KEARNEY ST, SUITE A, SPRINGFIELD, MO 65803-1652
- **Practice address phone:** (417) 862-2468
- **Practice address fax:** (417) 863-6775
- **Mailing address:** 2105 W KEARNEY ST, SUITE A, SPRINGFIELD, MO 65803-1652
- **Mailing address phone:** (417) 862-2468
- **Mailing address fax:** (417) 863-6775

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QD0000X | Dental Clinic/Center | 2003017125 | MO | Yes |

## Other

- **Enumeration date:** 10/07/2014
- **Last updated:** 10/07/2014