Provider Demographics
NPI:1164096665
Name:OWATONNA ENDODONTICS, LLC
Entity Type:Organization
Organization Name:OWATONNA ENDODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:507-242-1441
Mailing Address - Street 1:18599 VERNA LN
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-9730
Mailing Address - Country:US
Mailing Address - Phone:215-667-9440
Mailing Address - Fax:
Practice Address - Street 1:125 28TH ST NE STE 1
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-2560
Practice Address - Country:US
Practice Address - Phone:507-242-1441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-18
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty