Provider Demographics
NPI:1144312760
Name:EASTSIDE PERIODONTAL ASSOC PLLC
Entity type:Organization
Organization Name:EASTSIDE PERIODONTAL ASSOC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-757-5454
Mailing Address - Street 1:25523 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1824
Mailing Address - Country:US
Mailing Address - Phone:586-757-5454
Mailing Address - Fax:586-757-4147
Practice Address - Street 1:25523 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1824
Practice Address - Country:US
Practice Address - Phone:586-757-5454
Practice Address - Fax:586-757-4147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIB182751223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty