Provider Demographics
NPI:1558883181
Name:PERIODONTAL CARE, P.A.
Entity Type:Organization
Organization Name:PERIODONTAL CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:JD, CDFA, MS
Authorized Official - Phone:913-681-8100
Mailing Address - Street 1:5000 W 95TH ST STE 270
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66207-3300
Mailing Address - Country:US
Mailing Address - Phone:913-341-4141
Mailing Address - Fax:913-341-4432
Practice Address - Street 1:5000 W 95TH ST STE 270
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66207-3300
Practice Address - Country:US
Practice Address - Phone:913-341-4141
Practice Address - Fax:913-341-4432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100161371223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty