Provider Demographics
NPI:1982087078
Name:PERIO PLASTIC & IMPLANTOLOGY CENTER OF KOKOMO
Entity Type:Organization
Organization Name:PERIO PLASTIC & IMPLANTOLOGY CENTER OF KOKOMO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LADD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-455-0085
Mailing Address - Street 1:2333 W LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-8012
Mailing Address - Country:US
Mailing Address - Phone:765-455-0085
Mailing Address - Fax:
Practice Address - Street 1:3415 S LAFOUNTAIN ST
Practice Address - Street 2:SUITE H
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3802
Practice Address - Country:US
Practice Address - Phone:765-455-0085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011521A1223D0004X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty