Provider Demographics
NPI:1487847752
Name:ENDODONTIC PROFESSIONALS PA ST CLOUD ENDODONTICS
Entity Type:Organization
Organization Name:ENDODONTIC PROFESSIONALS PA ST CLOUD ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:KARN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:320-259-5078
Mailing Address - Street 1:1555 NORTHWAY DRIVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-259-5078
Mailing Address - Fax:320-259-1484
Practice Address - Street 1:1555 NORTHWAY DRIVE
Practice Address - Street 2:SUITE 210
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-259-5078
Practice Address - Fax:320-259-1484
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENDODONTIC PROFESSIONALS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN85754561223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty