Healthcare Provider Details

I. General information

NPI: 1124212790
Provider Name (Legal Business Name): PERIODONTICS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 SUNSET OFFICE DR STE C105
SAINT LOUIS MO
63127-1014
US

IV. Provider business mailing address

3555 SUNSET OFFICE DR STE C105
SAINT LOUIS MO
63127-1014
US

V. Phone/Fax

Practice location:
  • Phone: 314-965-3271
  • Fax: 314-965-8113
Mailing address:
  • Phone: 314-965-3271
  • Fax: 314-965-8113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number013097
License Number StateMO

VIII. Authorized Official

Name: DR. GEORGE V DUELLO
Title or Position: DR.
Credential: DDS,MS
Phone: 314-965-3271