MEDICARE: PREMIUM DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	22DI01842800	NJ

General Provider Information

NPI Number	:	1528557063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIUM DENTISTRY

Provider Business Mailing Address
First Line	:	6 W SPRUCE ST
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-5007
Country	:	US
Telephone Number	:	732-364-5100
Fax Number	:	201-927-3474

Provider Business Practice Location Address
First Line	:	6 W SPRUCE ST
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-5007
Country	:	US
Telephone Number	:	732-364-5100
Fax Number	:	201-927-3474

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	ANDRE SHIVRATTAN
Credential	:
Telephone Number	:	347-579-5159

Provider Enumeration Date	:	05/09/2018
Last Update Date	:	05/09/2018

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