Provider Demographics
NPI:1780340513
Name:PREMIERE FAMILY DENTISTRY OF TAHLEQUAH, PLLC
Entity type:Organization
Organization Name:PREMIERE FAMILY DENTISTRY OF TAHLEQUAH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-456-2555
Mailing Address - Street 1:1205 E ROSS BYP
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4188
Mailing Address - Country:US
Mailing Address - Phone:918-456-2555
Mailing Address - Fax:918-456-2444
Practice Address - Street 1:1205 E ROSS BYP
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4188
Practice Address - Country:US
Practice Address - Phone:918-456-2555
Practice Address - Fax:918-456-2444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental