Healthcare Provider Details

I. General information

NPI: 1538420385
Provider Name (Legal Business Name): PREMIER ORAL SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3370 BAYCHESTER AVE
BRONX NY
10475-1565
US

IV. Provider business mailing address

3370 BAYCHESTER AVE
BRONX NY
10475-1565
US

V. Phone/Fax

Practice location:
  • Phone: 718-671-2826
  • Fax: 718-671-2824
Mailing address:
  • Phone: 718-671-2826
  • Fax: 718-671-2824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number045325
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number043454
License Number StateNY

VIII. Authorized Official

Name: CATRINA MIDDLETON
Title or Position: BILLER
Credential:
Phone: 718-671-2826