Provider Demographics
NPI:1366614885
Name:PERIODONTAL & IMPLANT SPECIALISTS OF MADISON, LLC
Entity type:Organization
Organization Name:PERIODONTAL & IMPLANT SPECIALISTS OF MADISON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:STREICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-661-6412
Mailing Address - Street 1:2971 CHAPEL VALLEY RD.
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:57311-7240
Mailing Address - Country:US
Mailing Address - Phone:608-661-6400
Mailing Address - Fax:608-661-6414
Practice Address - Street 1:49 N WALBRIDGE AVE.
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717
Practice Address - Country:US
Practice Address - Phone:608-833-2578
Practice Address - Fax:608-203-7105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL HEALTH ASSOCIATES OF MADISON LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-25
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6136122300000X
WI6215122300000X
WI3628122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty