Provider Demographics
NPI:1336654102
Name:ELITE ENDODONTICS
Entity Type:Organization
Organization Name:ELITE ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:616-502-2846
Mailing Address - Street 1:6965 OAKHURST RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-5053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1135 S LAPEER RD STE A
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1432
Practice Address - Country:US
Practice Address - Phone:616-502-2846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-02
Last Update Date:2017-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010203731223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty