Provider Demographics
NPI:1326454042
Name:CORRIDOR ENDODONTICS PC
Entity Type:Organization
Organization Name:CORRIDOR ENDODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-800-9077
Mailing Address - Street 1:550 POND VIEW DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-2507
Mailing Address - Country:US
Mailing Address - Phone:319-459-1975
Mailing Address - Fax:319-459-1977
Practice Address - Street 1:550 POND VIEW DR
Practice Address - Street 2:SUITE 2
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-2507
Practice Address - Country:US
Practice Address - Phone:319-459-1975
Practice Address - Fax:319-459-1977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA09095261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental