Healthcare Provider Details

I. General information

NPI: 1366721292
Provider Name (Legal Business Name): PREMIER DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22801 NEWMAN ST
DEARBORN MI
48124-2200
US

IV. Provider business mailing address

22801 NEWMAN ST
DEARBORN MI
48124-2200
US

V. Phone/Fax

Practice location:
  • Phone: 313-274-8522
  • Fax: 313-274-5396
Mailing address:
  • Phone: 313-274-8522
  • Fax: 313-274-5396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901020370
License Number StateMI

VIII. Authorized Official

Name: POTA A RAKES
Title or Position: OWNER
Credential: DDS
Phone: 402-981-2996