Provider Demographics
NPI:1215619069
Name:MD ENDODONTICS, LLC
Entity type:Organization
Organization Name:MD ENDODONTICS, LLC
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:DIANDRETH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-268-2800
Mailing Address - Street 1:1804 FREDERICA RD STE B
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2044
Mailing Address - Country:US
Mailing Address - Phone:912-268-2800
Mailing Address - Fax:
Practice Address - Street 1:1804 FREDERICA RD STE B
Practice Address - Street 2:
Practice Address - City:SAINT SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2044
Practice Address - Country:US
Practice Address - Phone:912-268-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-02
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty