Provider Demographics
NPI:1073200820
Name:PREMIER DENTISTRY, LLC
Entity Type:Organization
Organization Name:PREMIER DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:DONGKYU
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-519-3557
Mailing Address - Street 1:3920 MYSTIC VALLEY PKWY APT 704
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6908
Mailing Address - Country:US
Mailing Address - Phone:617-519-3557
Mailing Address - Fax:
Practice Address - Street 1:348 N PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1197
Practice Address - Country:US
Practice Address - Phone:508-584-6070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty