Provider Demographics
NPI:1982934972
Name:SOUTHWEST ENDODONTICS
Entity type:Organization
Organization Name:SOUTHWEST ENDODONTICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:TISMENSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-576-8442
Mailing Address - Street 1:16055 108TH AVE
Mailing Address - Street 2:STE H
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5347
Mailing Address - Country:US
Mailing Address - Phone:708-460-9191
Mailing Address - Fax:709-460-9407
Practice Address - Street 1:16055 108TH AVE
Practice Address - Street 2:STE H
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5347
Practice Address - Country:US
Practice Address - Phone:708-460-9191
Practice Address - Fax:708-460-9407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021011351223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty