Provider Demographics
NPI:1508926841
Name:WAYZATA ENDODONTICS PA
Entity Type:Organization
Organization Name:WAYZATA ENDODONTICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:OTOOLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:952-476-0070
Mailing Address - Street 1:250 N CENTRAL AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391
Mailing Address - Country:US
Mailing Address - Phone:952-476-0070
Mailing Address - Fax:
Practice Address - Street 1:250 N CENTRAL AVE
Practice Address - Street 2:SUITE 303
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:2006-12-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN90111223E0200X
MN115431223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty