Healthcare Provider Details

I. General information

NPI: 1023428679
Provider Name (Legal Business Name): INNOVATIVE ENDODONTICS NORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2593 WEXFORD BAYNE RD SUITE 304
SEWICKLEY PA
15143-8608
US

IV. Provider business mailing address

2593 WEXFORD BAYNE RD SUITE 304
SEWICKLEY PA
15143-8608
US

V. Phone/Fax

Practice location:
  • Phone: 724-940-3963
  • Fax: 724-940-3965
Mailing address:
  • Phone: 724-940-3963
  • Fax: 724-940-3965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS037555
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MICHAEL E. LISIEN
Title or Position: PRESIDENT
Credential: DMD
Phone: 724-940-3963