MEDICARE: PERIODONTAL ASSOCIATES, LLP

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	:	1508355678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERIODONTAL ASSOCIATES, LLP

Provider Business Mailing Address
First Line	:	845 N MICHIGAN AVE STE 940W
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2216
Country	:	US
Telephone Number	:	312-751-1020
Fax Number	:	312-751-1231

Provider Business Practice Location Address
First Line	:	845 N MICHIGAN AVE STE 940W
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2216
Country	:	US
Telephone Number	:	312-751-1020
Fax Number	:	312-751-1231

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JENNIFER HOMOLA
Credential	:
Telephone Number	:	312-751-1020

Provider Enumeration Date	:	05/04/2018
Last Update Date	:	05/04/2018

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