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General NPI Number Information
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NPI Number | 1710394903
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Entity Type | Organization
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Legal Business Name | PREMIER DENTAL P C
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Dates
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Enumeration Date | 07/19/2014
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Last Update Date | 05/03/2023
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Provider Practice Location Address
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Address Line | 727 BROAD ST
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City | MERIDEN
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State | CT
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Zip | 06450-4341
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Country | US
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Telephone | 203-235-1415
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Fax |
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Provider Business Mailing Address
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Address Line | 727 BROAD ST
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City | MERIDEN
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State | CT
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Zip | 06450-4341
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST/PROSTHODONTIST
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Name | POLINA P SIMANOVICH
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Credential |
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Telephone | 203-235-1415
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 10452
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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