=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962653600
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERIODONTICS & IMPLANTS, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2008
-----------------------------------------------------
Last Update Date | 09/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 636 CHURCH ST SUITE 707
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-4508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-491-1880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 636 CHURCH ST SUITE 707
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-4508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-491-1880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PERIODONTIST
-----------------------------------------------------
Name | DR. RICHARD C PRENDERGAST
-----------------------------------------------------
Credential | D.D.S., M.S.
-----------------------------------------------------
Telephone | 847-491-1880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 021000596
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------