Provider Demographics
NPI:1699960724
Name:PREMIER DENTAL PARTNERS, LLC
Entity type:Organization
Organization Name:PREMIER DENTAL PARTNERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-960-9393
Mailing Address - Street 1:7282 CALM SUNSET
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-3400
Mailing Address - Country:US
Mailing Address - Phone:410-960-9393
Mailing Address - Fax:
Practice Address - Street 1:8615 RIDGELYS CHOICE DR
Practice Address - Street 2:SUITE 209
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-3026
Practice Address - Country:US
Practice Address - Phone:410-248-0025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD130091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty