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General NPI Number Information
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NPI Number | 1043344492
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Entity Type | Organization
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Legal Business Name | PERIODONTICS LTD.
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Dates
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Enumeration Date | 03/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4711 GOLF RD STE 101
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City | SKOKIE
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State | IL
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Zip | 60076-1239
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Country | US
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Telephone | 847-675-7555
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Fax | 847-675-3734
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Provider Business Mailing Address
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Address Line | 4711 GOLF RD STE 101
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City | SKOKIE
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State | IL
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Zip | 60076-1239
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Country | US
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Telephone | 847-675-7555
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Fax | 847-675-3734
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Authorized Official
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Title or Position | PARTNER
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Name | DR. STEPHEN P RUSSO
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Credential | DMD
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Telephone | 847-675-7555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State | IL
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