Healthcare Provider Details

I. General information

NPI: 1023350543
Provider Name (Legal Business Name): PERIODONTICS AND IMPLANT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8202 KELWOOD AVE
BATON ROUGE LA
70806-4801
US

IV. Provider business mailing address

4451 BLUEBONNET BLVD SUITE F
BATON ROUGE LA
70809-9646
US

V. Phone/Fax

Practice location:
  • Phone: 225-767-2273
  • Fax:
Mailing address:
  • Phone: 225-767-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5315
License Number StateLA

VIII. Authorized Official

Name: ANDRE BRUNI
Title or Position: OWNER
Credential: DDS
Phone: 225-767-2273