Healthcare Provider Details

I. General information

NPI: 1346541885
Provider Name (Legal Business Name): PERIOLLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 CENTRE STREET
NUTLEY NJ
07110
US

IV. Provider business mailing address

230 CENTRE STREET
NUTLEY NJ
07110
US

V. Phone/Fax

Practice location:
  • Phone: 973-661-2992
  • Fax: 973-661-3513
Mailing address:
  • Phone: 973-661-2992
  • Fax: 973-661-3513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDI 20033
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDI18768
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CORTNEY STUART
Title or Position: OFFICE MANAGER
Credential:
Phone: 973-661-2992