Provider Demographics
NPI:1295983781
Name:PERIODONTAL ASSOCIATES, LTD.
Entity type:Organization
Organization Name:PERIODONTAL ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-421-6464
Mailing Address - Street 1:189 GOVERNOR ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-3124
Mailing Address - Country:US
Mailing Address - Phone:401-421-6464
Mailing Address - Fax:401-272-3884
Practice Address - Street 1:189 GOVERNOR ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-3124
Practice Address - Country:US
Practice Address - Phone:401-421-6464
Practice Address - Fax:401-272-3884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI2740122300000X
RI1484122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty