Healthcare Provider Details

I. General information

NPI: 1194217166
Provider Name (Legal Business Name): MARIO ENDIAKOV DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7603 NORTH AVE
RIVER FOREST IL
60305-1133
US

IV. Provider business mailing address

7603 NORTH AVE
RIVER FOREST IL
60305-1133
US

V. Phone/Fax

Practice location:
  • Phone: 708-456-7787
  • Fax:
Mailing address:
  • Phone: 708-456-7787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019031843
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901602634
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2901602634
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number021003552
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: