Provider Demographics
NPI:1285883777
Name:WAYZATA ENDODONTICS, PA
Entity type:Organization
Organization Name:WAYZATA ENDODONTICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:TULKKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:952-476-0070
Mailing Address - Street 1:250 CENTRAL AVE N
Mailing Address - Street 2:SUITE 303
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1206
Mailing Address - Country:US
Mailing Address - Phone:952-476-0070
Mailing Address - Fax:
Practice Address - Street 1:1015 HIGHWAY 15 S
Practice Address - Street 2:PLAZA 15
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350
Practice Address - Country:US
Practice Address - Phone:952-476-0070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11543261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental