Healthcare Provider Details

I. General information

NPI: 1992960637
Provider Name (Legal Business Name): PERIODONTAL HEALTH SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 SEVERN AVE SUITE 402
METAIRIE LA
70002-5954
US

IV. Provider business mailing address

2540 SEVERN AVE SUITE 402
METAIRIE LA
70002-5954
US

V. Phone/Fax

Practice location:
  • Phone: 504-887-8205
  • Fax:
Mailing address:
  • Phone: 504-887-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3763
License Number StateLA

VIII. Authorized Official

Name: DR. AYMEE COSTALES-SPINDLER
Title or Position: OWNER
Credential: D.D.S.
Phone: 504-887-8205