Provider Demographics
NPI:1104255371
Name:GREAT LAKES ENDODONTICS
Entity type:Organization
Organization Name:GREAT LAKES ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:TERRANCE
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-528-0240
Mailing Address - Street 1:4815 W ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-4004
Mailing Address - Country:US
Mailing Address - Phone:218-772-0772
Mailing Address - Fax:
Practice Address - Street 1:4815 W ARROWHEAD RD
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-4004
Practice Address - Country:US
Practice Address - Phone:218-772-0772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12534261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental