Provider Demographics
NPI:1720551500
Name:PRIME DENTAL PLLC
Entity Type:Organization
Organization Name:PRIME DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SONA
Authorized Official - Middle Name:
Authorized Official - Last Name:FISENKOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-987-2879
Mailing Address - Street 1:32905 W 12 MILE RD STE 140
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3343
Mailing Address - Country:US
Mailing Address - Phone:248-987-2879
Mailing Address - Fax:248-715-6367
Practice Address - Street 1:32905 W 12 MILE RD STE 140
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3343
Practice Address - Country:US
Practice Address - Phone:248-987-2879
Practice Address - Fax:248-715-6367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-04
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1811380751OtherSELF