Provider Demographics
NPI:1821280272
Name:PREMIER DENTAL
Entity Type:Organization
Organization Name:PREMIER DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-869-6055
Mailing Address - Street 1:390 VINEYARD WAY
Mailing Address - Street 2:SUITE 505
Mailing Address - City:WEST GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19390-8835
Mailing Address - Country:US
Mailing Address - Phone:610-869-0655
Mailing Address - Fax:610-869-6099
Practice Address - Street 1:390 VINEYARD WAY
Practice Address - Street 2:SUITE 505
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390-8835
Practice Address - Country:US
Practice Address - Phone:610-869-0655
Practice Address - Fax:610-869-6099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0360401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty