Provider Demographics
NPI:1932329943
Name:PERIODONTAL ASSOCIATES
Entity Type:Organization
Organization Name:PERIODONTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:D
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-772-7459
Mailing Address - Street 1:612 BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2359
Mailing Address - Country:US
Mailing Address - Phone:207-772-7459
Mailing Address - Fax:207-874-6460
Practice Address - Street 1:612 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2359
Practice Address - Country:US
Practice Address - Phone:207-772-7459
Practice Address - Fax:207-874-6460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME22041223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty