Provider Demographics
NPI:1083227904
Name:PERIDOT DENTAL PLLC
Entity Type:Organization
Organization Name:PERIDOT DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLULEKE
Authorized Official - Middle Name:
Authorized Official - Last Name:JEBODA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-801-1439
Mailing Address - Street 1:3616 S LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-5629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3616 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-5629
Practice Address - Country:US
Practice Address - Phone:214-374-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-29
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental