Periodontal Associates of South Bend

Primary specialty

PeriodonticsTaxonomy code 1223P0300X

Legal business name

PERIODONTAL ASSOCIATES OF SOUTH BEND

Practice address

1918 Edison Rd
South Bend, IN 46617-1711

Phone

(574) 287-8900

NPI assigned

Jun 2, 2021

Organization subpart

No

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

Authorized official

Name

Gloria Royer

Title

Practice Manager

Phone

(765) 447-9319

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Periodontal Associates of South Bend Doing business as

Electronic endpoints 1

Locations

Practitioners 4

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

• Caroline Henderzahs, DDS, MSD

  • Periodontics
  • Lafayette, IN
  • NPI 1487545612
  NPD (past)
• Paul A. Sergio, D.D.S.

  • Periodontics
  • South Bend, IN
  • NPI 1922174432
  NPD (past)
• Apoorv Goel, BDS, MS, MSD

  • Periodontics
  • Nashville, TN
  • NPI 1083263321
  NPD (past)
• Ahmed Gamil Ibraheem, DDS, MSD

  • Periodontics
  • Tucson, AZ
  • NPI 1013540871
  NPD (past)

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

{
    "created_epoch": "1622592000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1622592000000",
    "number": "1962078642",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1918 EDISON RD",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466171711",
            "telephone_number": "574-287-8900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1918 EDISON RD",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466171711",
            "telephone_number": "574-287-8900"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PERIODONTAL ASSOCIATES OF SOUTH BEND",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-06-02",
        "last_updated": "2021-06-02",
        "certification_date": "2021-06-02",
        "status": "A",
        "authorized_official_last_name": "ROYER",
        "authorized_official_first_name": "GLORIA",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "765-447-9319"
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Periodontics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTAL LICENSE",
            "identifier": "12013130A",
            "state": "IN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "SouthBend",
            "affiliation": "N",
            "address_1": "1918 Edison Rd",
            "city": "South Bend",
            "state": "IN",
            "country_code": "US",
            "postal_code": "466171711",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Periodontal Associates of South Bend",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Frank Deno Pennoni, PA-C
• Warren Larry Penrod, FNP, BC
• Alizette Pereira
• Alma Perez, MSW
• Giovanni Perez
• Clarisa Perochena, MSW
• Julie Perron, LMFTA
• Daniel Perry
• Derrick Perry
• Kelsey Perry, MD CANDIDATE

• Periodontics in South Bend, IN
• Providers in South Bend, IN by specialty
• Periodontics in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 2, 2021; 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.