Provider Demographics
NPI:1043344492
Name:PERIODONTICS LTD.
Entity Type:Organization
Organization Name:PERIODONTICS LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-675-7555
Mailing Address - Street 1:4711 GOLF RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1239
Mailing Address - Country:US
Mailing Address - Phone:847-675-7555
Mailing Address - Fax:847-675-3734
Practice Address - Street 1:4711 GOLF RD STE 101
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1239
Practice Address - Country:US
Practice Address - Phone:847-675-7555
Practice Address - Fax:847-675-3734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty