Provider Demographics
NPI:1639241052
Name:PREMIER DENTAL GROUP OF WELLESLEY, P.C.
Entity Type:Organization
Organization Name:PREMIER DENTAL GROUP OF WELLESLEY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-237-3031
Mailing Address - Street 1:70 WALNUT ST. , STE102
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481
Mailing Address - Country:US
Mailing Address - Phone:781-237-3031
Mailing Address - Fax:781-237-3968
Practice Address - Street 1:70 WALNUT ST. , STE102
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481
Practice Address - Country:US
Practice Address - Phone:781-237-3031
Practice Address - Fax:781-237-3968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty