Provider Demographics
NPI:1124212790
Name:PERIODONTICS LTD
Entity Type:Organization
Organization Name:PERIODONTICS LTD
Other - Org Name:GEORGE V. DUELLO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:V
Authorized Official - Last Name:DUELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:314-965-3271
Mailing Address - Street 1:3555 SUNSET OFFICE DR STE C105
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1014
Mailing Address - Country:US
Mailing Address - Phone:314-965-3271
Mailing Address - Fax:314-965-8113
Practice Address - Street 1:3555 SUNSET OFFICE DR STE C105
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1014
Practice Address - Country:US
Practice Address - Phone:314-965-3271
Practice Address - Fax:314-965-8113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0130971223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty