Provider Demographics
NPI:1841343761
Name:ENDODONTIC SPECIALISTS, S.C.
Entity type:Organization
Organization Name:ENDODONTIC SPECIALISTS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BELARDI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-546-1900
Mailing Address - Street 1:10401 W LINCOLN AVE
Mailing Address - Street 2:STE. 104
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1255
Mailing Address - Country:US
Mailing Address - Phone:414-546-1900
Mailing Address - Fax:414-546-1901
Practice Address - Street 1:10401 W LINCOLN AVE
Practice Address - Street 2:STE. 104
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1255
Practice Address - Country:US
Practice Address - Phone:414-546-1900
Practice Address - Fax:414-546-1901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5520-0151223E0200X
WI4387-0151223E0200X
WI5534-0151223E0200X
WI1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI77631-001Medicaid