Provider Demographics
NPI:1760804983
Name:PERIDONTIC ASSOCIATES OF PORT HURON PLLC
Entity Type:Organization
Organization Name:PERIDONTIC ASSOCIATES OF PORT HURON PLLC
Other - Org Name:PERIODONTIC ASSOCIATES OF PORT HURON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:SOUYIAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-987-1400
Mailing Address - Street 1:1175 THOMAS EDISON DR
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-8500
Mailing Address - Country:US
Mailing Address - Phone:810-987-1400
Mailing Address - Fax:810-987-1349
Practice Address - Street 1:1175 THOMAS EDISON DR
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8500
Practice Address - Country:US
Practice Address - Phone:810-987-1400
Practice Address - Fax:810-987-1349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJS0192001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty