MEDICARE: PERIORAGE PLLC

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

General Provider Information

NPI Number	:	1962186056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERIORAGE PLLC

Provider Business Mailing Address
First Line	:	4450 E FLETCHER AVE STE B
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-4907
Country	:	US
Telephone Number	:	813-468-8882
Fax Number	:

Provider Business Practice Location Address
First Line	:	4450 E FLETCHER AVE STE B
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-4907
Country	:	US
Telephone Number	:	813-468-8882
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WAYNE KUO
Credential	:	DDS
Telephone Number	:	813-468-8882

Provider Enumeration Date	:	06/09/2023
Last Update Date	:	06/09/2023

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