Provider Demographics
NPI:1417284480
Name:WEST ENDODONTIC GROUP
Entity Type:Organization
Organization Name:WEST ENDODONTIC GROUP
Other - Org Name:LAKESIDE ENDODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-377-2668
Mailing Address - Street 1:1245 CHEYENNE AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9323
Mailing Address - Country:US
Mailing Address - Phone:262-377-2889
Mailing Address - Fax:262-377-2680
Practice Address - Street 1:1245 CHEYENNE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9323
Practice Address - Country:US
Practice Address - Phone:262-377-2889
Practice Address - Fax:262-377-2680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6129-151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty