Provider Demographics
NPI:1699899211
Name:SIGNATURE ENDODONTICS
Entity type:Organization
Organization Name:SIGNATURE ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WYATT
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-498-2115
Mailing Address - Street 1:2710 CAMINO CAPISTRANO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4802
Mailing Address - Country:US
Mailing Address - Phone:949-498-2115
Mailing Address - Fax:949-498-2473
Practice Address - Street 1:2710 CAMINO CAPISTRANO
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4802
Practice Address - Country:US
Practice Address - Phone:949-498-2115
Practice Address - Fax:949-498-2473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty