Provider Demographics
NPI:1588116040
Name:PRESTON DENTAL CARE PLLC
Entity type:Organization
Organization Name:PRESTON DENTAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:N
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-329-1989
Mailing Address - Street 1:202 TUNNELTON ST STE 214
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1452
Mailing Address - Country:US
Mailing Address - Phone:304-329-1989
Mailing Address - Fax:
Practice Address - Street 1:202 TUNNELTON ST STE 214
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1452
Practice Address - Country:US
Practice Address - Phone:304-329-1989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty