Provider Demographics
NPI:1508355678
Name:PERIODONTAL ASSOCIATES, LLP
Entity Type:Organization
Organization Name:PERIODONTAL ASSOCIATES, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HOMOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-751-1020
Mailing Address - Street 1:845 N MICHIGAN AVE STE 940W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2216
Mailing Address - Country:US
Mailing Address - Phone:312-751-1020
Mailing Address - Fax:312-751-1231
Practice Address - Street 1:845 N MICHIGAN AVE STE 940W
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2216
Practice Address - Country:US
Practice Address - Phone:312-751-1020
Practice Address - Fax:312-751-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty