Provider Demographics
NPI:1215655725
Name:406 PERIODONTICS, PLLC
Entity type:Organization
Organization Name:406 PERIODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SWOBODA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:206-931-4221
Mailing Address - Street 1:1648 ELLIS ST STE 202
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-8811
Mailing Address - Country:US
Mailing Address - Phone:206-931-4221
Mailing Address - Fax:
Practice Address - Street 1:1648 ELLIS ST STE 202
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-8811
Practice Address - Country:US
Practice Address - Phone:406-414-1303
Practice Address - Fax:406-577-2142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty