Provider Demographics
NPI:1700058302
Name:NORTHWEST ENDODONTIC SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:NORTHWEST ENDODONTIC SPECIALISTS, P.C.
Other - Org Name:CANTON OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARDSON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ODUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-493-6693
Mailing Address - Street 1:2205 RIVERSTONE BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5227
Mailing Address - Country:US
Mailing Address - Phone:678-493-6693
Mailing Address - Fax:678-493-6694
Practice Address - Street 1:2205 RIVERSTONE BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5227
Practice Address - Country:US
Practice Address - Phone:678-493-6693
Practice Address - Fax:678-493-6694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10232, 104161223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty