Healthcare Provider Details

I. General information

NPI: 1497348239
Provider Name (Legal Business Name): PERIODONTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 MAXWELL DR
HUDSON WI
54016-8709
US

IV. Provider business mailing address

8401 SEASONS PKWY
WOODBURY MN
55125-3414
US

V. Phone/Fax

Practice location:
  • Phone: 715-690-3050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: PATTY BARNARD
Title or Position: BUSINESS MANAGER
Credential:
Phone: 651-233-2140