Provider Demographics
NPI:1538577341
Name:ENDODONTIC PROFESSIONALS PA - ST ANTHONY ENDODONTICS
Entity type:Organization
Organization Name:ENDODONTIC PROFESSIONALS PA - ST ANTHONY ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-559-0859
Mailing Address - Street 1:3401 HIGHWAY 169 N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2413
Mailing Address - Country:US
Mailing Address - Phone:763-559-0859
Mailing Address - Fax:763-559-4356
Practice Address - Street 1:3905 SILVER LAKE RD NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-4352
Practice Address - Country:US
Practice Address - Phone:763-559-0859
Practice Address - Fax:763-559-4356
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENDODONTIC PROFESSIONALS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty