Provider Demographics
NPI:1699073924
Name:PREMIER DENTURE CENTER LLC
Entity type:Organization
Organization Name:PREMIER DENTURE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO DENTAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:419-874-5324
Mailing Address - Street 1:184 E SOUTH BOUNDARY ST STE 7
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-2527
Mailing Address - Country:US
Mailing Address - Phone:419-874-5324
Mailing Address - Fax:419-874-5324
Practice Address - Street 1:184 E SOUTH BOUNDARY ST STE 7
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-2527
Practice Address - Country:US
Practice Address - Phone:419-874-5324
Practice Address - Fax:419-874-5324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30023358122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty