=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497348239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERIODONTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2021
-----------------------------------------------------
Last Update Date | 02/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1610 MAXWELL DR
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-8709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-690-3050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8401 SEASONS PKWY
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125-3414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | PATTY BARNARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-233-2140
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------