Provider Demographics
NPI:1285047431
Name:PREMIERE ANESTHESIA FOR DENTISTRY
Entity type:Organization
Organization Name:PREMIERE ANESTHESIA FOR DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-759-7948
Mailing Address - Street 1:10154 WOODBURY DR
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9580
Mailing Address - Country:US
Mailing Address - Phone:724-759-7948
Mailing Address - Fax:724-759-7952
Practice Address - Street 1:106 VILLAGE PL
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-5611
Practice Address - Country:US
Practice Address - Phone:724-759-7948
Practice Address - Fax:724-759-7952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0361411223D0004X
PADS0354061223D0004X
PADS031543L1223D0004X
PADS029696L1223D0004X
PADP0006821223D0004X
PADA0316431223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Multi-Specialty