Provider Demographics
NPI:1386189272
Name:WAYZATA ENDODONTICS, P.A.
Entity Type:Organization
Organization Name:WAYZATA ENDODONTICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TULKKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-476-0070
Mailing Address - Street 1:101 LAKE ST W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1576
Mailing Address - Country:US
Mailing Address - Phone:952-476-0070
Mailing Address - Fax:
Practice Address - Street 1:101 LAKE STREET WEST
Practice Address - Street 2:SUITE 100
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391
Practice Address - Country:US
Practice Address - Phone:952-476-0070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty