Healthcare Provider Details

I. General information

NPI: 1134539935
Provider Name (Legal Business Name): PREMIER DENTAL & IMPLANT STUDIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20321 GRANDE OAK SHOPPES BLVD STE 316
ESTERO FL
33928-7697
US

IV. Provider business mailing address

20321 GRANDE OAK SHOPPES BLVD STE 316
ESTERO FL
33928-7697
US

V. Phone/Fax

Practice location:
  • Phone: 239-992-0325
  • Fax: 239-992-0329
Mailing address:
  • Phone: 239-992-0325
  • Fax: 239-992-0329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN15549
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN15449
License Number StateFL

VIII. Authorized Official

Name: DIANA COLMENARES
Title or Position: PRACTICE MANAGER
Credential:
Phone: 239-254-9933