Provider Demographics
NPI:1972504843
Name:ENDODONTIC SPECIALISTS OF LACROSSE LTD
Entity Type:Organization
Organization Name:ENDODONTIC SPECIALISTS OF LACROSSE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:B
Authorized Official - Last Name:NORDEEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-783-3636
Mailing Address - Street 1:2700 NATIONAL DR
Mailing Address - Street 2:STE 102
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650
Mailing Address - Country:US
Mailing Address - Phone:608-783-3636
Mailing Address - Fax:608-783-3639
Practice Address - Street 1:2700 NATIONAL DR
Practice Address - Street 2:STE 102
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650
Practice Address - Country:US
Practice Address - Phone:608-783-3636
Practice Address - Fax:608-783-3639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty