Healthcare Provider Details

I. General information

NPI: 1740359546
Provider Name (Legal Business Name): PERIODONTAL SPECIALISTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 VIKING DR NW
ROCHESTER MN
55901-3522
US

IV. Provider business mailing address

2112 VIKING DR NW
ROCHESTER MN
55901-3522
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-1338
  • Fax:
Mailing address:
  • Phone: 507-288-1338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number07829
License Number StateMN

VIII. Authorized Official

Name: TANYIA BUCHER
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 507-451-8151