Provider Demographics
NPI:1841398658
Name:PERIODONTICS INCORPORATED
Entity Type:Organization
Organization Name:PERIODONTICS INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:M
Authorized Official - Last Name:FERTIK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:401-274-2600
Mailing Address - Street 1:167 GANO STREET
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906
Mailing Address - Country:US
Mailing Address - Phone:401-274-2600
Mailing Address - Fax:401-421-7875
Practice Address - Street 1:167 GANO STREET
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-274-2600
Practice Address - Fax:401-421-7875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN02345122300000X
RIDEN02700122300000X
RIDEN01328122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty