Provider Demographics
NPI:1528557063
Name:PREMIUM DENTISTRY
Entity Type:Organization
Organization Name:PREMIUM DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIVRATTAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-579-5159
Mailing Address - Street 1:6 W SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5007
Mailing Address - Country:US
Mailing Address - Phone:732-364-5100
Mailing Address - Fax:201-927-3474
Practice Address - Street 1:6 W SPRUCE ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5007
Practice Address - Country:US
Practice Address - Phone:732-364-5100
Practice Address - Fax:201-927-3474
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL ASSOCIATES OF LAKEWOOD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01842800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty