MEDICARE: EVANSVILLE ENDODONTICS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics

General Provider Information

NPI Number	:	1538424023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVANSVILLE ENDODONTICS, INC.

Provider Business Mailing Address
First Line	:	7321 EAGLE CREST BLVD
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-8157
Country	:	US
Telephone Number	:	812-402-9600
Fax Number	:	812-402-9605

Provider Business Practice Location Address
First Line	:	7321 EAGLE CREST BLVD
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-8157
Country	:	US
Telephone Number	:	812-402-9600
Fax Number	:	812-402-9605

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KRIEGER WEBB BRASSEALE
Credential	:	DDS
Telephone Number	:	812-402-9600

Provider Enumeration Date	:	07/10/2012
Last Update Date	:	07/10/2012

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