Provider Demographics
NPI:1154619583
Name:PERIODONTIC PLLC
Entity type:Organization
Organization Name:PERIODONTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:DARANY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:248-851-1034
Mailing Address - Street 1:22801 NEWMAN ST.
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1740
Mailing Address - Country:US
Mailing Address - Phone:313-274-8522
Mailing Address - Fax:313-274-5396
Practice Address - Street 1:40400 E. ANN ARBOR RD.
Practice Address - Street 2:SUITE 204A
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170
Practice Address - Country:US
Practice Address - Phone:734-459-4077
Practice Address - Fax:734-459-4084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010153151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty