Provider Demographics
NPI: | 1003186628 |
---|---|
Name: | ADVANCED UPSTSTE ENDODONTICS |
Entity Type: | Organization |
Organization Name: | ADVANCED UPSTSTE ENDODONTICS |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | MICHAEL |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | PFISTER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS, MS |
Authorized Official - Phone: | 862-624-9229 |
Mailing Address - Street 1: | PO BOX 1936 |
Mailing Address - Street 2: | |
Mailing Address - City: | CLEMSON |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29633-1936 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 864-624-9229 |
Mailing Address - Fax: | 864-624-9595 |
Practice Address - Street 1: | 101 FINLEY ST |
Practice Address - Street 2: | |
Practice Address - City: | CLEMSON |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29631-1583 |
Practice Address - Country: | US |
Practice Address - Phone: | 864-624-9229 |
Practice Address - Fax: | 864-624-9595 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-01-12 |
Last Update Date: | 2012-01-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SC | 766 ENDO | 1223E0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223E0200X | Dental Providers | Dentist | Endodontics | Group - Single Specialty |