Provider Demographics
NPI:1528112562
Name:ENDODONTIC ASSOCIATES, INC.
Entity type:Organization
Organization Name:ENDODONTIC ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SHIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-432-2813
Mailing Address - Street 1:4640 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6826
Mailing Address - Country:US
Mailing Address - Phone:260-432-2813
Mailing Address - Fax:
Practice Address - Street 1:4640 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6826
Practice Address - Country:US
Practice Address - Phone:260-432-2813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120077051223E0200X
IN120077211223E0200X
IN120104801223E0200X
IN120076031223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty