Provider Demographics
NPI:1427398411
Name:PREMIER DENTAL
Entity Type:Organization
Organization Name:PREMIER DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:Y
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-733-5469
Mailing Address - Street 1:1514 WHITE BEAR AVE N
Mailing Address - Street 2:B
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-1624
Mailing Address - Country:US
Mailing Address - Phone:817-733-5469
Mailing Address - Fax:
Practice Address - Street 1:1514 WHITE BEAR AVE N
Practice Address - Street 2:B
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-1624
Practice Address - Country:US
Practice Address - Phone:817-733-5469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND128591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty