Provider Demographics
NPI:1932467461
Name:CLERMONT ENDODONTIC SPECIALIST, P.A.
Entity Type:Organization
Organization Name:CLERMONT ENDODONTIC SPECIALIST, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/INSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:265 HATTERAS AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-7400
Mailing Address - Country:US
Mailing Address - Phone:352-394-0150
Mailing Address - Fax:352-243-0654
Practice Address - Street 1:265 HATTERAS AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-7400
Practice Address - Country:US
Practice Address - Phone:352-394-0150
Practice Address - Fax:352-243-0654
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLERMONT ENDODONTIC SPECIALIST, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty