Provider Demographics
NPI:1679932818
Name:PREMIER FAMILY DENTISTRY PLLC
Entity type:Organization
Organization Name:PREMIER FAMILY DENTISTRY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:ADEYEMI
Authorized Official - Last Name:ISIOYE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-543-4747
Mailing Address - Street 1:3024 KINGSBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-5121
Mailing Address - Country:US
Mailing Address - Phone:718-543-4747
Mailing Address - Fax:718-884-6137
Practice Address - Street 1:3024 KINGSBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5121
Practice Address - Country:US
Practice Address - Phone:718-543-4747
Practice Address - Fax:718-884-6137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050241261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02419776Medicaid