MEDICARE: PERIDOT DENTAL PLLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1083227904
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERIDOT DENTAL PLLC

Provider Business Mailing Address
First Line	:	3616 S LANCASTER RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-5629
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3616 S LANCASTER RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-5629
Country	:	US
Telephone Number	:	214-374-7100
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. OLULEKE JEBODA
Credential	:	DMD
Telephone Number	:	217-801-1439

Provider Enumeration Date	:	08/29/2020
Last Update Date	:	08/29/2020

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Directions to “PERIDOT DENTAL PLLC ” Practice Location

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