Provider Demographics
NPI:1730586579
Name:ADVANCED PERIODONTICS & IMPLANTS PLLC
Entity type:Organization
Organization Name:ADVANCED PERIODONTICS & IMPLANTS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:RECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:507-226-3706
Mailing Address - Street 1:2112 VIKING DR NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-3522
Mailing Address - Country:US
Mailing Address - Phone:507-208-9124
Mailing Address - Fax:507-218-0326
Practice Address - Street 1:2112 VIKING DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3522
Practice Address - Country:US
Practice Address - Phone:507-208-9124
Practice Address - Fax:507-218-0326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND127331223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty