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General NPI Number Information
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NPI Number | 1508355678
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Entity Type | Organization
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Legal Business Name | PERIODONTAL ASSOCIATES, LLP
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Dates
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Enumeration Date | 05/04/2018
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Last Update Date | 05/04/2018
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Provider Practice Location Address
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Address Line | 845 N MICHIGAN AVE STE 940W
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City | CHICAGO
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State | IL
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Zip | 60611-2216
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Country | US
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Telephone | 312-751-1020
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Fax | 312-751-1231
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Provider Business Mailing Address
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Address Line | 845 N MICHIGAN AVE STE 940W
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City | CHICAGO
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State | IL
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Zip | 60611-2216
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Country | US
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Telephone | 312-751-1020
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Fax | 312-751-1231
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JENNIFER HOMOLA
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Credential |
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Telephone | 312-751-1020
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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 |
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