Healthcare Provider Details

I. General information

NPI: 1336219856
Provider Name (Legal Business Name): PERIODONTICS LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N WABASH AVE STE 919
CHICAGO IL
60602-1932
US

IV. Provider business mailing address

111 N WABASH AVE STE 919
CHICAGO IL
60602-1932
US

V. Phone/Fax

Practice location:
  • Phone: 312-641-2572
  • Fax: 312-641-6621
Mailing address:
  • Phone: 312-641-2572
  • Fax: 312-641-6621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. STEPHEN P RUSSO
Title or Position: PERIODONTIST
Credential: DMD MS
Phone: 312-641-2572