Provider Demographics
NPI:1063941391
Name:PREMIER ORTHODONTICS LLC
Entity type:Organization
Organization Name:PREMIER ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYRAH
Authorized Official - Middle Name:IMTIAZ
Authorized Official - Last Name:QURAISHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:317-998-7645
Mailing Address - Street 1:8860 ZIONSVILLE RD STE B
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-1043
Mailing Address - Country:US
Mailing Address - Phone:317-998-7645
Mailing Address - Fax:
Practice Address - Street 1:8860 ZIONSVILLE RD STE B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1043
Practice Address - Country:US
Practice Address - Phone:317-998-7645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012422A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty