Provider Demographics
NPI:1962651687
Name:PREMIER DENTAL,PC
Entity Type:Organization
Organization Name:PREMIER DENTAL,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-602-9533
Mailing Address - Street 1:25 MAXINE AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-3606
Mailing Address - Country:US
Mailing Address - Phone:917-602-9533
Mailing Address - Fax:
Practice Address - Street 1:1155 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-3025
Practice Address - Country:US
Practice Address - Phone:718-241-8050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00295143122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty