Provider Demographics
NPI:1770703688
Name:PERIODONTAL CARE, PA
Entity type:Organization
Organization Name:PERIODONTAL CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:RAJEK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-432-0010
Mailing Address - Street 1:7493 147TH ST W
Mailing Address - Street 2:SUITE 105
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-4505
Mailing Address - Country:US
Mailing Address - Phone:952-432-0010
Mailing Address - Fax:952-432-0011
Practice Address - Street 1:7493 147TH ST W
Practice Address - Street 2:SUITE 105
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4505
Practice Address - Country:US
Practice Address - Phone:952-432-0010
Practice Address - Fax:952-432-0011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN80371223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty