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General NPI Number Information
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NPI Number | 1104103548
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Entity Type | Organization
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Legal Business Name | PREMIER DENTAL
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Dates
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Enumeration Date | 11/14/2011
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Last Update Date | 11/14/2011
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Provider Practice Location Address
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Address Line | 39 WACO DR
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City | LONDON
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State | KY
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Zip | 40741-8327
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Country | US
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Telephone | 606-877-3002
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Fax | 606-877-3024
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Provider Business Mailing Address
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Address Line | 39 WACO DR
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City | LONDON
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State | KY
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Zip | 40741-8327
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Country | US
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Telephone | 606-877-3002
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Fax | 606-877-3024
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Authorized Official
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Title or Position | DENTIST
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Name | TERRI BROWN
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Credential | DMD
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Telephone | 606-877-3002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 7672
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License Number State | KY
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