Eastside Periodontal Assoc PLLC

Primary specialty

PeriodonticsTaxonomy code 1223P0300X

License

B18275 Issued in MI

Legal business name

EASTSIDE PERIODONTAL ASSOC PLLC

Practice address

25523 Van Dyke Ave
Center Line, MI 48015-1824

Phone

(586) 757-5454

Fax

(586) 757-4147

NPI assigned

Sep 29, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Jennifer Lynn Wise

Title

Office Manager

Phone

(586) 757-5454

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159488000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1144312760",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "25523 VAN DYKE AVE",
            "city": "CENTER LINE",
            "state": "MI",
            "postal_code": "480151824",
            "telephone_number": "586-757-5454",
            "fax_number": "586-757-4147"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "25523 VAN DYKE AVE",
            "city": "CENTER LINE",
            "state": "MI",
            "postal_code": "480151824",
            "telephone_number": "586-757-5454",
            "fax_number": "586-757-4147"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EASTSIDE PERIODONTAL ASSOC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-29",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "WISE",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "LYNN",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "586-757-5454",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Periodontics",
            "state": "MI",
            "license": "B18275",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Periodontics in Center Line, MI
• Providers in Center Line, MI by specialty
• Periodontics in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.