MEDICARE: PREMIUMSMILE PLLC

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	1223D0001X	Public Health Dentistry

General Provider Information

NPI Number	:	1831978238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIUMSMILE PLLC

Provider Business Mailing Address
First Line	:	6421 W 43RD ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77092-4005
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6421 W 43RD ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77092-4005
Country	:	US
Telephone Number	:	832-941-4010
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	PHILIP ONYIRIMBA
Credential	:
Telephone Number	:	469-233-1987

Provider Enumeration Date	:	09/25/2023
Last Update Date	:	09/25/2023

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