Provider Demographics
NPI:1194895219
Name:ENDODONTIC SPECIALISTS LLC
Entity type:Organization
Organization Name:ENDODONTIC SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER LLC
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:SIERASKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-663-9521
Mailing Address - Street 1:3601 GENERAL ELECTRIC ROAD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704
Mailing Address - Country:US
Mailing Address - Phone:309-663-9521
Mailing Address - Fax:309-663-0346
Practice Address - Street 1:3601 GENERAL ELECTRIC ROAD
Practice Address - Street 2:SUITE 6
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704
Practice Address - Country:US
Practice Address - Phone:309-663-9521
Practice Address - Fax:309-663-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty