NPIMap

Organization Active NPI

Periodontics LTD.

  • Periodontics
  • Chicago, IL
National Provider Identifier
1336219856
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
PeriodonticsTaxonomy code 1223P0300X
Legal business name
PERIODONTICS LTD.
Practice address
111 N Wabash Ave Ste 919
Chicago, IL 60602-1932
Phone
(312) 641-2572
Fax
(312) 641-6621
NPI assigned
Nov 9, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Dr. Stephen P Russo, DMD MS
Title
Periodontist
Phone
(312) 641-2572

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
PeriodonticsGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0300X IL Primary

Addresses

Primary practice location

111 N Wabash Ave Ste 919
Chicago, IL 60602-1932

Mailing address

111 N Wabash Ave Ste 919
Chicago, IL 60602-1932
Phone (312) 641-2572

National Provider Directory

National Provider Directory
Tax ID family
Periodontics LTD2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

111 N Wabash Ave
Ste 919
Chicago, IL 60602
Phone (312) 641-2572

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1163030400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1336219856",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "111 N WABASH AVE STE 919",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606021932",
            "telephone_number": "312-641-2572",
            "fax_number": "312-641-6621"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 N WABASH AVE STE 919",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606021932",
            "telephone_number": "312-641-2572",
            "fax_number": "312-641-6621"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PERIODONTICS LTD.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-09",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "RUSSO",
        "authorized_official_first_name": "STEPHEN",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "PERIODONTIST",
        "authorized_official_telephone_number": "312-641-2572",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD MS"
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Periodontics",
            "state": "IL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Chicago, IL

Sources for this page

  • 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.