Provider Demographics
NPI:1295568913
Name:PERIO1 LLC
Entity type:Organization
Organization Name:PERIO1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOQUEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-869-8884
Mailing Address - Street 1:903 RUSSELL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3282
Mailing Address - Country:US
Mailing Address - Phone:301-869-8884
Mailing Address - Fax:301-869-8870
Practice Address - Street 1:903 RUSSELL AVE STE 300
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3282
Practice Address - Country:US
Practice Address - Phone:301-869-8884
Practice Address - Fax:301-869-8870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental