Provider Demographics
NPI:1386305779
Name:PINE LAKES ENDODONTICS PA
Entity type:Organization
Organization Name:PINE LAKES ENDODONTICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:DROLL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:217-520-2397
Mailing Address - Street 1:13046 FALCON DR STE 2
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-4201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13046 FALCON DR STE 2
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-4201
Practice Address - Country:US
Practice Address - Phone:217-520-2397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty