Provider Demographics
NPI:1174081301
Name:SAN ANGELO ENDODONTICS, PC
Entity type:Organization
Organization Name:SAN ANGELO ENDODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:R
Authorized Official - Last Name:SOUTHARD
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE, FHFMA
Authorized Official - Phone:806-797-4455
Mailing Address - Street 1:2014 W BEAUREGARD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3813
Mailing Address - Country:US
Mailing Address - Phone:325-947-3040
Mailing Address - Fax:806-797-2460
Practice Address - Street 1:2014 W BEAUREGARD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3813
Practice Address - Country:US
Practice Address - Phone:325-947-3040
Practice Address - Fax:806-797-2460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty