Provider Demographics
NPI:1003961061
Name:PREMIER DENTAL CARE
Entity Type:Organization
Organization Name:PREMIER DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-691-1701
Mailing Address - Street 1:PO BOX 970084
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-0084
Mailing Address - Country:US
Mailing Address - Phone:801-691-1701
Mailing Address - Fax:801-335-6551
Practice Address - Street 1:685 CITADEL DR E
Practice Address - Street 2:SUITE 302
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5314
Practice Address - Country:US
Practice Address - Phone:719-596-1011
Practice Address - Fax:719-596-6748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1044711223G0001X
CO60351223G0001X
CO67161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty