Provider Demographics
NPI:1093908360
Name:ENDODONTIC PROFESSIONALS PA PLYMOUTH ENDODONTICS
Entity Type:Organization
Organization Name:ENDODONTIC PROFESSIONALS PA PLYMOUTH 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:763-559-4356
Mailing Address - Street 1:3401 HWY 169 N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441
Mailing Address - Country:US
Mailing Address - Phone:763-559-0859
Mailing Address - Fax:763-559-4356
Practice Address - Street 1:3401 HWY 169 N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441
Practice Address - Country:US
Practice Address - Phone:763-559-0859
Practice Address - Fax:763-559-4356
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
MN10937201223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty