Healthcare Provider Details

I. General information

NPI: 1609048743
Provider Name (Legal Business Name): PERIOWEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7810 TERREY PINE CT
EDEN PRAIRIE MN
55347-1186
US

IV. Provider business mailing address

7810 TERREY PINE CT
EDEN PRAIRIE MN
55347-1186
US

V. Phone/Fax

Practice location:
  • Phone: 952-567-7457
  • Fax:
Mailing address:
  • Phone: 952-567-7457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberS13
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDRES ROBERTO SANCHEZ
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 952-393-3634