Provider Demographics
NPI:1689171076
Name:PREMIER MOBILE DENTISTRY OF VA LLC
Entity Type:Organization
Organization Name:PREMIER MOBILE DENTISTRY OF VA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:NUSS
Authorized Official - Last Name:RABEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-776-0006
Mailing Address - Street 1:6224 PROVINCE LN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-3574
Mailing Address - Country:US
Mailing Address - Phone:122-532-4594
Mailing Address - Fax:225-752-0196
Practice Address - Street 1:6224 PROVINCE LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-3574
Practice Address - Country:US
Practice Address - Phone:225-324-5945
Practice Address - Fax:225-752-0196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental