Provider Demographics
NPI:1013075480
Name:ENDODONTIC & PERIODONTIC ASSOCIATES, LTD
Entity Type:Organization
Organization Name:ENDODONTIC & PERIODONTIC ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO & PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:J. MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CVENGROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-922-1165
Mailing Address - Street 1:18130 HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2507
Mailing Address - Country:US
Mailing Address - Phone:708-799-2550
Mailing Address - Fax:708-799-2568
Practice Address - Street 1:18130 HALSTED ST
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2507
Practice Address - Country:US
Practice Address - Phone:708-799-2550
Practice Address - Fax:708-799-2568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0600000641223E0200X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX IDENTIFICATION