Provider Demographics
NPI:1962078642
Name:PERIODONTAL ASSOCIATES OF SOUTH BEND
Entity type:Organization
Organization Name:PERIODONTAL ASSOCIATES OF SOUTH BEND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-447-9319
Mailing Address - Street 1:1918 EDISON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1711
Mailing Address - Country:US
Mailing Address - Phone:574-287-8900
Mailing Address - Fax:
Practice Address - Street 1:1918 EDISON RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1711
Practice Address - Country:US
Practice Address - Phone:574-287-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12013130AOtherDENTAL LICENSE