Provider Demographics
NPI:1295245181
Name:PERIODONTAL ASSOCIATES OF NORTH FLORIDA, PLLC
Entity type:Organization
Organization Name:PERIODONTAL ASSOCIATES OF NORTH FLORIDA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:E
Authorized Official - Last Name:COLON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:850-562-6111
Mailing Address - Street 1:2160 CAPITAL CIR NE STE 100
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4391
Mailing Address - Country:US
Mailing Address - Phone:850-562-6111
Mailing Address - Fax:850-562-7263
Practice Address - Street 1:2160 CAPITAL CIR NE STE 100
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4391
Practice Address - Country:US
Practice Address - Phone:850-562-6111
Practice Address - Fax:850-562-7263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental