Provider Demographics
NPI:1891319273
Name:JANESVILLE ENDODONTICS
Entity Type:Organization
Organization Name:JANESVILLE ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SOFYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-520-2228
Mailing Address - Street 1:1616 N RANDALL AVE STE 180
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1155
Mailing Address - Country:US
Mailing Address - Phone:608-314-9000
Mailing Address - Fax:608-314-3241
Practice Address - Street 1:1616 N RANDALL AVE STE 180
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-1155
Practice Address - Country:US
Practice Address - Phone:608-314-9000
Practice Address - Fax:608-314-3241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1001926OtherSTATE LICENSE
WI1316415086OtherNPI NUMBER