Provider Demographics
NPI:1306561410
Name:PREMIER ORTHODONTIC AND PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:PREMIER ORTHODONTIC AND PEDIATRIC DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-421-5667
Mailing Address - Street 1:1037 S STATE ROAD 7 STE 215
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6140
Mailing Address - Country:US
Mailing Address - Phone:561-333-4568
Mailing Address - Fax:561-225-1136
Practice Address - Street 1:1037 S STATE ROAD 7 STE 215
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6140
Practice Address - Country:US
Practice Address - Phone:561-421-5667
Practice Address - Fax:561-225-1136
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER GENERAL AND COSMETIC DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty