Provider Demographics
NPI:1730331778
Name:ADVANCED SOUTHLAKE ENDODONTICS, PLLC
Entity type:Organization
Organization Name:ADVANCED SOUTHLAKE ENDODONTICS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-488-3636
Mailing Address - Street 1:1100 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6357
Mailing Address - Country:US
Mailing Address - Phone:817-488-3636
Mailing Address - Fax:817-421-2372
Practice Address - Street 1:1100 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6357
Practice Address - Country:US
Practice Address - Phone:817-488-3636
Practice Address - Fax:817-421-2372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental