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General NPI Number Information
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NPI Number | 1104255371
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Entity Type | Organization
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Legal Business Name | GREAT LAKES ENDODONTICS
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Dates
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Enumeration Date | 11/07/2013
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Last Update Date | 11/07/2013
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Provider Practice Location Address
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Address Line | 4815 W ARROWHEAD RD
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City | HERMANTOWN
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State | MN
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Zip | 55811-4004
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Country | US
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Telephone | 218-772-0772
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Fax |
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Provider Business Mailing Address
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Address Line | 4815 W ARROWHEAD RD
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City | HERMANTOWN
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State | MN
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Zip | 55811-4004
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Country | US
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Telephone | 218-772-0772
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. MARK TERRANCE PHILLIPS
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Credential | DDS
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Telephone | 651-528-0240
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | D12534
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License Number State | MN
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