Provider Demographics
NPI:1962653600
Name:PERIODONTICS & IMPLANTS, LTD.
Entity Type:Organization
Organization Name:PERIODONTICS & IMPLANTS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:PRENDERGAST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:847-491-1880
Mailing Address - Street 1:636 CHURCH ST
Mailing Address - Street 2:SUITE 707
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4508
Mailing Address - Country:US
Mailing Address - Phone:847-491-1880
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST
Practice Address - Street 2:SUITE 707
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4508
Practice Address - Country:US
Practice Address - Phone:847-491-1880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210005961223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty