MEDICARE: PERIODONTIC 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	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1205014669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERIODONTIC PLLC

Provider Business Mailing Address
First Line	:	22801 NEWMAN ST.
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-1740
Country	:	US
Telephone Number	:	313-274-8522
Fax Number	:

Provider Business Practice Location Address
First Line	:	3589 FORT ST
Second Line	:
City	:	WYANDOTTE
State	:	MI
Zip	:	48192-6315
Country	:	US
Telephone Number	:	734-281-1414
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID G DARANY
Credential	:	DDS, MS
Telephone Number	:	313-274-8522

Provider Enumeration Date	:	02/07/2008
Last Update Date	:	03/14/2013

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Directions to “PERIODONTIC PLLC ” Practice Location

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