Provider Demographics
NPI:1154496818
Name:ENDODONTIC ASSOCIATES OF MICHIGAN PLLC
Entity type:Organization
Organization Name:ENDODONTIC ASSOCIATES OF MICHIGAN PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-647-7930
Mailing Address - Street 1:5825 S. MAIN STREET
Mailing Address - Street 2:STE. 103
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346
Mailing Address - Country:US
Mailing Address - Phone:248-620-0002
Mailing Address - Fax:248-620-0025
Practice Address - Street 1:5825 S. MAIN STREET
Practice Address - Street 2:STE. 103
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346
Practice Address - Country:US
Practice Address - Phone:248-620-0002
Practice Address - Fax:248-620-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI93451223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty