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General NPI Number Information
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NPI Number | 1720551500
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Entity Type | Organization
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Legal Business Name | PRIME DENTAL PLLC
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Dates
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Enumeration Date | 01/04/2019
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Last Update Date | 12/05/2022
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Provider Practice Location Address
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Address Line | 32905 W 12 MILE RD STE 140
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City | FARMINGTON HILLS
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State | MI
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Zip | 48334-3343
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Country | US
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Telephone | 248-987-2879
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Fax | 248-715-6367
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Provider Business Mailing Address
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Address Line | 32905 W 12 MILE RD STE 140
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City | FARMINGTON HILLS
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State | MI
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Zip | 48334-3343
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Country | US
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Telephone | 248-987-2879
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Fax | 248-715-6367
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | SONA FISENKOVA
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Credential | DDS
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Telephone | 248-987-2879
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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