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General NPI Number Information
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NPI Number | 1578666442
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Entity Type | Organization
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Legal Business Name | ENDODONTIC ASSOCIATES OF NWO LLC
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Dates
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Enumeration Date | 09/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 715 N DIXIE
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City | WAPAKONETA
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State | OH
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Zip | 45895-0024
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Country | US
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Telephone | 419-738-6944
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Fax | 419-738-1444
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Provider Business Mailing Address
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Address Line | PO BOX 24 715 N DIXIE
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City | WAPAKONETA
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State | OH
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Zip | 45895-0024
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Country | US
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Telephone | 419-738-6944
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Fax | 419-738-1444
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Authorized Official
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Title or Position | PRESIDENT MEMBER
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Name | DR. ALAN BYRON MIKESELL
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Credential | DDS MS
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Telephone | 419-738-6944
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 30021456
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 30021501
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 30012922
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License Number State | OH
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