Provider Demographics
NPI:1083366785
Name:PREMIER DENTAL GROUP PC
Entity Type:Organization
Organization Name:PREMIER DENTAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-204-4307
Mailing Address - Street 1:1290 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2113
Mailing Address - Country:US
Mailing Address - Phone:207-204-4307
Mailing Address - Fax:
Practice Address - Street 1:1800 WOODBURY AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-3238
Practice Address - Country:US
Practice Address - Phone:603-436-8822
Practice Address - Fax:603-431-3948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty