Provider Demographics
NPI:1447410501
Name:PERIODONTIC SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:PERIODONTIC SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GABREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-432-0577
Mailing Address - Street 1:7750 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4174
Mailing Address - Country:US
Mailing Address - Phone:260-432-0577
Mailing Address - Fax:206-432-0578
Practice Address - Street 1:7750 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4174
Practice Address - Country:US
Practice Address - Phone:260-432-0577
Practice Address - Fax:206-432-0578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty