MEDICARE: ENDODONTIC ASSOCIATES, INC.

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	12007705	IN
2	1223E0200X	Endodontics	12007721	IN
3	1223E0200X	Endodontics	12010480	IN
4	1223E0200X	Endodontics	12007603	IN

General Provider Information

NPI Number	:	1528112562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENDODONTIC ASSOCIATES, INC.

Provider Business Mailing Address
First Line	:	4640 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-6826
Country	:	US
Telephone Number	:	260-432-2813
Fax Number	:

Provider Business Practice Location Address
First Line	:	4640 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-6826
Country	:	US
Telephone Number	:	260-432-2813
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JUDY E SHIVELY
Credential	:
Telephone Number	:	260-432-2813

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	08/22/2020

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