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General NPI Number Information
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NPI Number | 1740359546
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Entity Type | Organization
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Legal Business Name | PERIODONTAL SPECIALISTS, PA
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2112 VIKING DR NW
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City | ROCHESTER
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State | MN
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Zip | 55901-3522
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Country | US
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Telephone | 507-288-1338
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Fax |
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Provider Business Mailing Address
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Address Line | 2112 VIKING DR NW
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City | ROCHESTER
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State | MN
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Zip | 55901-3522
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Country | US
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Telephone | 507-288-1338
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Fax |
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | TANYIA BUCHER
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Credential |
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Telephone | 507-451-8151
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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 | 07829
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License Number State | MN
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