Provider Demographics
NPI:1962847020
Name:PREMIER FAMILY DENTAL PC
Entity Type:Organization
Organization Name:PREMIER FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:RATHOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-772-4222
Mailing Address - Street 1:520 CLIFTON AVE STE 4
Mailing Address - Street 2:4
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-3247
Mailing Address - Country:US
Mailing Address - Phone:973-772-4222
Mailing Address - Fax:973-772-7652
Practice Address - Street 1:520 CLIFTON AVE STE 4
Practice Address - Street 2:4
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-3247
Practice Address - Country:US
Practice Address - Phone:973-772-4222
Practice Address - Fax:973-772-7652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0227391122300000X
NJDI24432001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0227391Medicaid
NJ0255891Medicaid