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General NPI Number Information
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NPI Number | 1588163364
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Entity Type | Organization
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Legal Business Name | ADVANCED ENDODONTICS, PC
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Dates
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Enumeration Date | 02/07/2018
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Last Update Date | 02/07/2018
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Provider Practice Location Address
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Address Line | 103 S. GREENLEAF STREET SUITE K
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City | GURNEE
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State | IL
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Zip | 60031
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Country | US
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Telephone | 847-782-0048
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Fax | 847-782-0102
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Provider Business Mailing Address
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Address Line | 921 OLD TRAIL RD
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City | HIGLAND PARK
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State | IL
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Zip | 60035
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Country | US
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Telephone | 847-782-0048
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Fax | 847-782-0102
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Authorized Official
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Title or Position | PRESIDENT OWNER DDS
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Name | DR. JOHN E STUPARITZ
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Credential | DDS, MS
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Telephone | 847-840-7580
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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 | 021.001771
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019.020999
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License Number State | IL
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