Provider Demographics
NPI:1952093494
Name:PERIODONTAL CARE NORTH, LLC
Entity type:Organization
Organization Name:PERIODONTAL CARE NORTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-379-9498
Mailing Address - Street 1:5707 NW 64TH TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64151-2382
Mailing Address - Country:US
Mailing Address - Phone:816-741-3830
Mailing Address - Fax:816-741-2693
Practice Address - Street 1:5707 NW 64TH TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64151-2382
Practice Address - Country:US
Practice Address - Phone:816-741-3830
Practice Address - Fax:816-741-2693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty