Provider Demographics
NPI:1669864542
Name:PERIO-DENTAL IMPLANTS, LLC
Entity Type:Organization
Organization Name:PERIO-DENTAL IMPLANTS, LLC
Other - Org Name:THE CENTER FOR PERIODONTICS AND DENTAL IMPLANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:FABIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-712-6320
Mailing Address - Street 1:6301 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3415
Mailing Address - Country:US
Mailing Address - Phone:608-709-1240
Mailing Address - Fax:608-819-8395
Practice Address - Street 1:6301 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3415
Practice Address - Country:US
Practice Address - Phone:608-709-1240
Practice Address - Fax:608-819-8395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty