MEDICARE: PERIODONTAL ASSOCIATES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	9008	CT

General Provider Information

NPI Number	:	1558364091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERIODONTAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	61 4TH ST
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06905-5010
Country	:	US
Telephone Number	:	203-323-5900
Fax Number	:

Provider Business Practice Location Address
First Line	:	61 4TH ST
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06905-5010
Country	:	US
Telephone Number	:	203-323-5900
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. ROBERT CHUNG
Credential	:	DDS
Telephone Number	:	203-323-5900

Provider Enumeration Date	:	05/29/2005
Last Update Date	:	08/22/2020

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