Provider Demographics
NPI:1194217166
Name:ENDIAKOV, MARIO (DMD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:ENDIAKOV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13874 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-3123
Mailing Address - Country:US
Mailing Address - Phone:313-834-4900
Mailing Address - Fax:
Practice Address - Street 1:13874 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-3123
Practice Address - Country:US
Practice Address - Phone:313-834-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031843122300000X
MI2951000970390200000X
MI25163100626122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program