Basic Information
| Provider Information | |||||||||
| NPI: | 1679064901 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHPORT PERIODONTICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5021 WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531444292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626546770 | ||||||||
| FaxNumber: | 2626546727 | ||||||||
| Practice Location | |||||||||
| Address1: | 5021 WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626546770 | ||||||||
| FaxNumber: | 2626546727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2018 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | JENKINS | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2626546770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Periodontics |
No ID Information.