Provider Demographics
NPI:1902512163
Name:PREMIER ENDODONTICS, PC
Entity Type:Organization
Organization Name:PREMIER ENDODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:WISWALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:605-868-6422
Mailing Address - Street 1:13170 BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8523
Mailing Address - Country:US
Mailing Address - Phone:605-868-6422
Mailing Address - Fax:
Practice Address - Street 1:703 QUINCY ST STE 2
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3674
Practice Address - Country:US
Practice Address - Phone:605-868-6422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty