Healthcare Provider Details

I. General information

NPI: 1386815744
Provider Name (Legal Business Name): PREMIER DENTAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1264B N LAKE ST
AURORA IL
60506-2453
US

IV. Provider business mailing address

1264B N LAKE ST
AURORA IL
60506-2453
US

V. Phone/Fax

Practice location:
  • Phone: 630-801-9028
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019024846
License Number StateIL

VIII. Authorized Official

Name: PHIL KURAL
Title or Position: DIRECTOR DOCTOR CREDENTIALING
Credential:
Phone: 312-274-4526