Provider Demographics
NPI:1437393139
Name:PERICO, PC
Entity Type:Organization
Organization Name:PERICO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:J
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:781-596-2220
Mailing Address - Street 1:90 HUMPHREY ST
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-2542
Mailing Address - Country:US
Mailing Address - Phone:781-596-2220
Mailing Address - Fax:781-598-8050
Practice Address - Street 1:90 HUMPHREY ST
Practice Address - Street 2:
Practice Address - City:SWAMPSCOTT
Practice Address - State:MA
Practice Address - Zip Code:01907-2542
Practice Address - Country:US
Practice Address - Phone:781-596-2220
Practice Address - Fax:781-598-8050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA116621223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty