MEDICARE: SOUTHSIDE ENDODONTICS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	401007706	VA

General Provider Information

NPI Number	:	1053494260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE ENDODONTICS, PC

Provider Business Mailing Address
First Line	:	2425 BOULEVARD
Second Line	:	SUITE 8
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-2324
Country	:	US
Telephone Number	:	804-520-0000
Fax Number	:	804-520-2111

Provider Business Practice Location Address
First Line	:	2425 BOULEVARD
Second Line	:	SUITE 8
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-2324
Country	:	US
Telephone Number	:	804-520-0000
Fax Number	:	804-520-2111

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ELLEN RIVES OERTEL
Credential	:	DDS
Telephone Number	:	804-520-0000

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	03/06/2009

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