Healthcare Provider Details

I. General information

NPI: 1447486600
Provider Name (Legal Business Name): PRIME DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3112 CRANBERRY HWY
EAST WAREHAM MA
02538-4804
US

IV. Provider business mailing address

3112 CRANBERRY HWY
EAST WAREHAM MA
02538-4804
US

V. Phone/Fax

Practice location:
  • Phone: 508-771-7753
  • Fax: 508-771-7753
Mailing address:
  • Phone: 508-771-7751
  • Fax: 508-771-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21084
License Number StateMA

VIII. Authorized Official

Name: DR. SANG J LEE
Title or Position: OWNER
Credential: DMD
Phone: 508-771-7751