Provider Demographics
NPI:1932263506
Name:PERIODONTICS ASSOCIATES, LLP
Entity Type:Organization
Organization Name:PERIODONTICS ASSOCIATES, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RANDAL
Authorized Official - Last Name:COMEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-989-0267
Mailing Address - Street 1:3839 W CONGRESS ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-6000
Mailing Address - Country:US
Mailing Address - Phone:337-989-0267
Mailing Address - Fax:337-989-9030
Practice Address - Street 1:3839 W CONGRESS ST
Practice Address - Street 2:SUITE D
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-6000
Practice Address - Country:US
Practice Address - Phone:337-989-0267
Practice Address - Fax:337-989-9030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA31291223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAU16975Medicare UPIN
LAU61697Medicare UPIN