Provider Demographics
NPI:1386997906
Name:LRC PERIODONTICS AND IMPLANTS, LLC
Entity type:Organization
Organization Name:LRC PERIODONTICS AND IMPLANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:RICHARDS
Authorized Official - Last Name:CAPATI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:402-943-7711
Mailing Address - Street 1:1099 BELT LINE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-4380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1099 BELT LINE RD
Practice Address - Street 2:SUITE A
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4380
Practice Address - Country:US
Practice Address - Phone:402-943-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0276821223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty