Provider Demographics
NPI:1346541885
Name:PERIOLLP
Entity Type:Organization
Organization Name:PERIOLLP
Other - Org Name:ADVANCED PERIODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:STUART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-661-2992
Mailing Address - Street 1:230 CENTRE STREET
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110
Mailing Address - Country:US
Mailing Address - Phone:973-661-2992
Mailing Address - Fax:973-661-3513
Practice Address - Street 1:230 CENTRE STREET
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110
Practice Address - Country:US
Practice Address - Phone:973-661-2992
Practice Address - Fax:973-661-3513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI187681223P0300X
NJDI 200331223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty