52D2212705 CLIA NUMBER - PREMIER PERIODONTICS

Laboratory Demographics

CLIA Number: 52D2212705

Facility Name: PREMIER PERIODONTICS

Facility Address:
2933 W LAYTON AVE
GREENFIELD, WI
ZIP 53221
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Facility Phone Number: 414 282-2642

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1770911976

Taxonomy: 1223P0300X - Dentist
That specialty of dentistry which encompasses the prevention, diagnosis and treatment of diseases of the supporting and surrounding tissues of the teeth or their substitutes and the maintenance of the health, function and esthetics of these structures and tissues.

CLIA Record

Field Name	Field Value
CLIA Number	52D2212705
LAB Type	Practitioner Other
Facility Name	PREMIER PERIODONTICS
Street	2933 W LAYTON AVE
City	GREENFIELD
State	WI
ZIP	53221
Phone	414 282-2642
CertificateType	4
CertificateEffectiveDate	2/5/2023
CertificateExpirationDate	2/4/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024