Provider Demographics
NPI:1013402007
Name:PC ENDO SOUTH PA
Entity Type:Organization
Organization Name:PC ENDO SOUTH PA
Other - Org Name:ADVANCED ENDODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-404-5550
Mailing Address - Street 1:1471 JOHNS LAKE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-7005
Mailing Address - Country:US
Mailing Address - Phone:321-204-6471
Mailing Address - Fax:407-674-2539
Practice Address - Street 1:1471 JOHNS LAKE RD STE 1
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-7005
Practice Address - Country:US
Practice Address - Phone:321-204-6471
Practice Address - Fax:407-674-2539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty