Provider Demographics
NPI:1669710331
Name:PERIODONTAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:PERIODONTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCALLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PHD
Authorized Official - Phone:503-620-2807
Mailing Address - Street 1:18753 SW MARTINAZZI AVE
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-6808
Mailing Address - Country:US
Mailing Address - Phone:503-620-2807
Mailing Address - Fax:503-620-2807
Practice Address - Street 1:18753 SW MARTINAZZI AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-6808
Practice Address - Country:US
Practice Address - Phone:503-620-2807
Practice Address - Fax:503-968-5419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD69001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty