Provider Demographics
NPI:1053494260
Name:SOUTHSIDE ENDODONTICS, PC
Entity Type:Organization
Organization Name:SOUTHSIDE ENDODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:RIVES
Authorized Official - Last Name:OERTEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-520-0000
Mailing Address - Street 1:2425 BOULEVARD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2324
Mailing Address - Country:US
Mailing Address - Phone:804-520-0000
Mailing Address - Fax:804-520-2111
Practice Address - Street 1:2425 BOULEVARD
Practice Address - Street 2:SUITE 8
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2324
Practice Address - Country:US
Practice Address - Phone:804-520-0000
Practice Address - Fax:804-520-2111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA4010077061223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty