Organization Name: | GREAT LAKES ENDODONTICS |
NPI Number: | 1104255371 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | MARK TERRANCE PHILLIPS (DENTIST) |
Mailing Address: | 4815 W Arrowhead Rd Hermantown |
State: | MN US |
Postal Code: | 558114004 |
Phone Number: | 2187720772 |
Fax Number: | |
NPI Enumeration Date: | 11/07/2013 |
NPI Last Update Date: | 11/07/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QD0000X |
License Number: | D12534 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MN |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Dental |
Taxonomy Definition: |