Healthcare Provider Details

I. General information

NPI: 1982934972
Provider Name (Legal Business Name): SOUTHWEST ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2010
Last Update Date: 05/28/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16055 108TH AVE STE H
ORLAND PARK IL
60467-5347
US

IV. Provider business mailing address

16055 108TH AVE STE H
ORLAND PARK IL
60467-5347
US

V. Phone/Fax

Practice location:
  • Phone: 708-460-9191
  • Fax: 708-460-9407
Mailing address:
  • Phone: 708-460-9191
  • Fax: 709-460-9407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number02101135
License Number StateIL

VIII. Authorized Official

Name: DR. VLADIMIR TISMENSKY
Title or Position: PRESIDENT
Credential: DDS
Phone: 708-576-8442