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General NPI Number Information
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NPI Number | 1427398411
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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 | 02/27/2013
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Last Update Date | 02/27/2013
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Provider Practice Location Address
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Address Line | 1514 WHITE BEAR AVE N B
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City | SAINT PAUL
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State | MN
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Zip | 55106-1624
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Country | US
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Telephone | 817-733-5469
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Fax |
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Provider Business Mailing Address
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Address Line | 1514 WHITE BEAR AVE N B
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City | SAINT PAUL
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State | MN
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Zip | 55106-1624
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Country | US
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Telephone | 817-733-5469
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. TOM Y LEE
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Credential | DDS
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Telephone | 817-733-5469
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D12859
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License Number State | MN
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