Provider Demographics
NPI:1578666442
Name:ENDODONTIC ASSOCIATES OF NWO LLC
Entity Type:Organization
Organization Name:ENDODONTIC ASSOCIATES OF NWO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:BYRON
Authorized Official - Last Name:MIKESELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:419-738-6944
Mailing Address - Street 1:PO BOX 24
Mailing Address - Street 2:715 N DIXIE
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895-0024
Mailing Address - Country:US
Mailing Address - Phone:419-738-6944
Mailing Address - Fax:419-738-1444
Practice Address - Street 1:715 N DIXIE
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-0024
Practice Address - Country:US
Practice Address - Phone:419-738-6944
Practice Address - Fax:419-738-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300129221223E0200X
OH300214561223E0200X
OH300215011223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty