Provider Demographics
NPI:1235440884
Name:PERIODONTAL HEALTH CENTER, PL
Entity Type:Organization
Organization Name:PERIODONTAL HEALTH CENTER, PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:STILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:727-847-1239
Mailing Address - Street 1:5522 GULF DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-4022
Mailing Address - Country:US
Mailing Address - Phone:727-847-1239
Mailing Address - Fax:727-845-4595
Practice Address - Street 1:5522 GULF DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-4022
Practice Address - Country:US
Practice Address - Phone:727-847-1239
Practice Address - Fax:727-845-4595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN171941223P0300X
FLDN68881223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty