Provider Demographics
NPI:1497174155
Name:RIVERWALK PERIODONTICS LLC
Entity Type:Organization
Organization Name:RIVERWALK PERIODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:BEARD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:773-383-3878
Mailing Address - Street 1:280 MAIN ST
Mailing Address - Street 2:QUARTZ C-106
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-8501
Mailing Address - Country:US
Mailing Address - Phone:970-766-6000
Mailing Address - Fax:
Practice Address - Street 1:280 MAIN ST
Practice Address - Street 2:QUARTZ C-106
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-8501
Practice Address - Country:US
Practice Address - Phone:970-766-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00202129261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental