Provider Demographics
NPI:1588810980
Name:NORTHSIDE ENDODONTICS, PC
Entity Type:Organization
Organization Name:NORTHSIDE ENDODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:SLAVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MSD
Authorized Official - Phone:795-759-9630
Mailing Address - Street 1:1400 S PILGRIM BLVD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47396-9250
Mailing Address - Country:US
Mailing Address - Phone:765-759-9630
Mailing Address - Fax:765-759-9640
Practice Address - Street 1:1400 S PILGRIM BLVD
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:IN
Practice Address - Zip Code:47396-9250
Practice Address - Country:US
Practice Address - Phone:765-759-9630
Practice Address - Fax:765-759-9640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54000837A1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty