Provider Demographics
NPI:1861645145
Name:PENN PREMIER DENTAL, INC.
Entity Type:Organization
Organization Name:PENN PREMIER DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAMLOO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-363-5810
Mailing Address - Street 1:194 EXTON SQUARE MALL
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-2440
Mailing Address - Country:US
Mailing Address - Phone:610-363-5810
Mailing Address - Fax:610-594-0667
Practice Address - Street 1:194 EXTON SQUARE MALL
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2440
Practice Address - Country:US
Practice Address - Phone:610-363-5810
Practice Address - Fax:610-594-0667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS036955122300000X
PADS037327122300000X
PADS037059122300000X, 1223E0200X
PADS036832122300000X
PADS023283Y1223P0221X
PADS0361381223P0300X
PADS0368301223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========OtherTAX ID