Provider Demographics
NPI:1710431788
Name:PERIODONTICS AND IMPLANT DENTISTRY, LLC
Entity Type:Organization
Organization Name:PERIODONTICS AND IMPLANT DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:G
Authorized Official - Last Name:HUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-369-2091
Mailing Address - Street 1:6754 LINDERMANN AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-5603
Mailing Address - Country:US
Mailing Address - Phone:262-632-5455
Mailing Address - Fax:262-632-2858
Practice Address - Street 1:6754 LINDERMANN AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-5603
Practice Address - Country:US
Practice Address - Phone:262-632-5455
Practice Address - Fax:262-632-2858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental