Provider Demographics
NPI:1578680765
Name:SUBURBAN PERIODONTAL ASSOCIATES LIMITED
Entity Type:Organization
Organization Name:SUBURBAN PERIODONTAL ASSOCIATES LIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRUENDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-368-0605
Mailing Address - Street 1:120 OAKBROOK CENTER
Mailing Address - Street 2:SUITE 600
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523
Mailing Address - Country:US
Mailing Address - Phone:630-368-0605
Mailing Address - Fax:630-368-9616
Practice Address - Street 1:120 OAKBROOK CENTER
Practice Address - Street 2:SUITE 600
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523
Practice Address - Country:US
Practice Address - Phone:630-368-0605
Practice Address - Fax:630-368-9616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0216014791223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty