Provider Demographics
NPI:1386100048
Name:PRIMECAREDENTALLLC
Entity type:Organization
Organization Name:PRIMECAREDENTALLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTEHSAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-288-0469
Mailing Address - Street 1:11550 PHILADELPHIA RD STE 118
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-1305
Mailing Address - Country:US
Mailing Address - Phone:410-256-4868
Mailing Address - Fax:
Practice Address - Street 1:11550 PHILADELPHIA RD STE 118
Practice Address - Street 2:
Practice Address - City:WHITE MARSH
Practice Address - State:MD
Practice Address - Zip Code:21162-1305
Practice Address - Country:US
Practice Address - Phone:410-256-4868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental