Provider Demographics
NPI:1003009374
Name:ENDODONTIC PROFESSIONALS PA ARBOR LAKES ENDODONTICS
Entity Type:Organization
Organization Name:ENDODONTIC PROFESSIONALS PA ARBOR LAKES ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:KARN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:763-416-3619
Mailing Address - Street 1:12000 ELM CREEK BLVD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369
Mailing Address - Country:US
Mailing Address - Phone:763-416-3619
Mailing Address - Fax:763-416-3695
Practice Address - Street 1:12000 ELM CREEK BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:763-416-3619
Practice Address - Fax:763-416-3695
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENDODONTIC PROFESSIONALS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN65000031223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty