Provider Demographics
NPI:1689232936
Name:PREMIER FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:PREMIER FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RANI
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGHESE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-532-7177
Mailing Address - Street 1:39 CROSS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-1666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39 CROSS ST STE 101
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-1666
Practice Address - Country:US
Practice Address - Phone:978-532-7177
Practice Address - Fax:978-531-9939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-02
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1205199569Medicaid