Healthcare Provider Details

I. General information

NPI: 1386001006
Provider Name (Legal Business Name): PREMIER DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 HANOVER PIKE
MANCHESTER MD
21102-1914
US

IV. Provider business mailing address

2730 HANOVER PIKE
MANCHESTER MD
21102-1914
US

V. Phone/Fax

Practice location:
  • Phone: 410-374-4882
  • Fax: 410-374-0702
Mailing address:
  • Phone: 410-374-4882
  • Fax: 410-374-0702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13189
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL SOBOL
Title or Position: OWNER
Credential: DDS
Phone: 410-374-4882