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General NPI Number Information
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NPI Number | 1730331778
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Entity Type | Organization
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Legal Business Name | ADVANCED SOUTHLAKE ENDODONTICS, PLLC
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Dates
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Enumeration Date | 10/22/2008
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Last Update Date | 10/22/2008
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Provider Practice Location Address
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Address Line | 1100 E SOUTHLAKE BLVD SUITE 400
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6357
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Country | US
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Telephone | 817-488-3636
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Fax | 817-421-2372
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Provider Business Mailing Address
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Address Line | 1100 E SOUTHLAKE BLVD SUITE 400
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6357
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Country | US
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Telephone | 817-488-3636
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Fax | 817-421-2372
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Authorized Official
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Title or Position | MEMBER
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Name | DR. CHARLES MICHAEL LARSEN
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Credential | DDS
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Telephone | 817-488-3636
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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 |
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License Number State | NULL
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