Provider Demographics
NPI:1770911976
Name:PREMIER PERIODONTICS LLC
Entity type:Organization
Organization Name:PREMIER PERIODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:E
Authorized Official - Last Name:POPPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-358-3370
Mailing Address - Street 1:2933 W LAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2626
Mailing Address - Country:US
Mailing Address - Phone:414-282-2642
Mailing Address - Fax:414-282-1952
Practice Address - Street 1:2933 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2626
Practice Address - Country:US
Practice Address - Phone:414-282-2642
Practice Address - Fax:414-282-1952
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STEPPING STONE DENTAL PARTNERS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7160-151223P0300X
WI5001847-151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty