Provider Demographics
NPI:1790431278
Name:PRIME DENTAL ASSOCIATES PC
Entity Type:Organization
Organization Name:PRIME DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIKTORIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSHNIR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:815-385-4140
Mailing Address - Street 1:2301 W. JOHNSBURG RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60051
Mailing Address - Country:US
Mailing Address - Phone:815-385-4140
Mailing Address - Fax:815-331-0241
Practice Address - Street 1:2301 W. JOHNSBURG RD
Practice Address - Street 2:
Practice Address - City:JOHNSBURG
Practice Address - State:IL
Practice Address - Zip Code:60051
Practice Address - Country:US
Practice Address - Phone:815-385-4140
Practice Address - Fax:815-331-0241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty