Provider Demographics
NPI:1851411367
Name:PREMIERE MAXILLOFACIAL SURGEONS, INC.
Entity Type:Organization
Organization Name:PREMIERE MAXILLOFACIAL SURGEONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:TETTEH-MARTEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:626-665-9279
Mailing Address - Street 1:3132 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-5638
Mailing Address - Country:US
Mailing Address - Phone:707-442-1775
Mailing Address - Fax:707-444-2821
Practice Address - Street 1:3132 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-5638
Practice Address - Country:US
Practice Address - Phone:707-442-1775
Practice Address - Fax:707-444-2821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA521191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty