Provider Demographics
NPI:1194885376
Name:SOUTHEASTERN ENDODONTICS
Entity type:Organization
Organization Name:SOUTHEASTERN ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:423-892-4727
Mailing Address - Street 1:2030 HAMILTON PLACE BLVD
Mailing Address - Street 2:STE. 380
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-6038
Mailing Address - Country:US
Mailing Address - Phone:423-892-4727
Mailing Address - Fax:423-899-7992
Practice Address - Street 1:2030 HAMILTON PLACE BLVD
Practice Address - Street 2:STE. 380
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-6038
Practice Address - Country:US
Practice Address - Phone:423-892-4727
Practice Address - Fax:423-899-7992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty