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General NPI Number Information
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NPI Number | 1467864256
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Entity Type | Organization
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Legal Business Name | THE PERIOCLINIC LLC
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Dates
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Enumeration Date | 05/28/2014
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Last Update Date | 05/28/2014
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Provider Practice Location Address
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Address Line | 337 METAIRIE RD SUITE 301
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City | METAIRIE
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State | LA
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Zip | 70005-4338
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Country | US
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Telephone | 504-831-0800
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Fax | 504-831-0866
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Provider Business Mailing Address
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Address Line | 337 METAIRIE RD SUITE 301
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City | METAIRIE
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State | LA
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Zip | 70005-4338
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Country | US
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Telephone | 504-831-0800
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Fax | 504-831-0866
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Authorized Official
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Title or Position | DOCTOR/MEMBER
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Name | DR. HISHAM F NASR
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Credential | DDS
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Telephone | 504-831-0800
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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 | 4832
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License Number State | LA
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