Provider Demographics
NPI:1821156241
Name:VALLEY PERIODONTICS, S.C.
Entity Type:Organization
Organization Name:VALLEY PERIODONTICS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:S.
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-731-3224
Mailing Address - Street 1:2535 NORTHER ROAD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914
Mailing Address - Country:US
Mailing Address - Phone:920-731-3224
Mailing Address - Fax:920-731-2910
Practice Address - Street 1:2535 NORTHER ROAD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914
Practice Address - Country:US
Practice Address - Phone:920-731-3224
Practice Address - Fax:920-731-2910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty