Provider Demographics
NPI:1497348239
Name:PERIODONTAL CENTER
Entity Type:Organization
Organization Name:PERIODONTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-233-2140
Mailing Address - Street 1:8401 SEASONS PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1610 MAXWELL DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8709
Practice Address - Country:US
Practice Address - Phone:715-690-3050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty