Healthcare Provider Details

I. General information

NPI: 1790432219
Provider Name (Legal Business Name): PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 LEHIGH AVE STE 210
GLENVIEW IL
60026-1691
US

IV. Provider business mailing address

1S224 SUMMIT AVE STE 205
OAKBROOK TERRACE IL
60181-3943
US

V. Phone/Fax

Practice location:
  • Phone: 630-627-3930
  • Fax:
Mailing address:
  • Phone: 630-627-3930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOLLY WALSH
Title or Position: PRACTICE OPERATIONS DIRECTOR
Credential:
Phone: 630-627-3930