Provider Demographics
NPI:1841489739
Name:PERIODONTICS PA
Entity type:Organization
Organization Name:PERIODONTICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:NITZELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-797-7410
Mailing Address - Street 1:19816 LEITERSBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1444
Mailing Address - Country:US
Mailing Address - Phone:301-797-7410
Mailing Address - Fax:301-797-7412
Practice Address - Street 1:19816 LEITERSBURG PIKE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-1444
Practice Address - Country:US
Practice Address - Phone:301-797-7410
Practice Address - Fax:301-797-7412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty