Provider Demographics
NPI:1659017838
Name:PREMIERE DENTAL SPA AT MADISON
Entity type:Organization
Organization Name:PREMIERE DENTAL SPA AT MADISON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TENESHIA
Authorized Official - Middle Name:EARLINE
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:256-469-6428
Mailing Address - Street 1:102 ST LOUIS ST STE D
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8028
Mailing Address - Country:US
Mailing Address - Phone:256-469-6428
Mailing Address - Fax:
Practice Address - Street 1:102 ST LOUIS ST STE D
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-8028
Practice Address - Country:US
Practice Address - Phone:256-469-6428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIERE DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental