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General NPI Number Information
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NPI Number | 1770911976
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Entity Type | Organization
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Legal Business Name | PREMIER PERIODONTICS LLC
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Dates
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Enumeration Date | 10/24/2013
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Last Update Date | 10/24/2013
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Provider Practice Location Address
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Address Line | 2933 W LAYTON AVE
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City | GREENFIELD
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State | WI
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Zip | 53221-2626
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Country | US
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Telephone | 414-282-2642
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Fax | 414-282-1952
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Provider Business Mailing Address
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Address Line | 2933 W LAYTON AVE
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City | GREENFIELD
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State | WI
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Zip | 53221-2626
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Country | US
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Telephone | 414-282-2642
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Fax | 414-282-1952
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Authorized Official
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Title or Position | PARTNER
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Name | GENEVIEVE E POPPE
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Credential |
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Telephone | 608-358-3370
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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 | 7160-15
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 5001847-15
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License Number State | WI
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