Provider Demographics
NPI:1134539935
Name:PREMIER DENTAL & IMPLANT STUDIO
Entity type:Organization
Organization Name:PREMIER DENTAL & IMPLANT STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLMENARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-254-9933
Mailing Address - Street 1:20321 GRANDE OAK SHOPPES BLVD STE 316
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-7697
Mailing Address - Country:US
Mailing Address - Phone:239-992-0325
Mailing Address - Fax:239-992-0329
Practice Address - Street 1:20321 GRANDE OAK SHOPPES BLVD STE 316
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-7697
Practice Address - Country:US
Practice Address - Phone:239-992-0325
Practice Address - Fax:239-992-0329
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLLIER ORAL SURGERY & IMPLANT CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN154491223S0112X
FLDN155491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty