Provider Demographics
NPI:1558656124
Name:PRIME TIME DENTAL
Entity Type:Organization
Organization Name:PRIME TIME DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:SULIMANOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-277-7645
Mailing Address - Street 1:1548 DEKALB ST
Mailing Address - Street 2:
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19401-3425
Mailing Address - Country:US
Mailing Address - Phone:610-277-7645
Mailing Address - Fax:610-277-7644
Practice Address - Street 1:1548 DEKALB ST
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19401-3425
Practice Address - Country:US
Practice Address - Phone:610-277-7645
Practice Address - Fax:610-277-7644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-12
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA00389NO07133833305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization