Provider Demographics
NPI:1538126263
Name:ENDODONTICS PC
Entity Type:Organization
Organization Name:ENDODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOK KEEPER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-565-9118
Mailing Address - Street 1:22731 NEWMAN ST STE 125
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124
Mailing Address - Country:US
Mailing Address - Phone:313-565-9118
Mailing Address - Fax:313-565-2672
Practice Address - Street 1:22731 NEWMAN ST STE 125
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124
Practice Address - Country:US
Practice Address - Phone:313-565-9118
Practice Address - Fax:313-565-2672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI95631223E0200X
MI93661223E0200X
MI105461223E0200X
MI144841223E0200X
MI161521223E0200X
MI136371223E0200X
MI182271223E0200X
MI83571223E0200X
MI173621223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty