# PREMIUM DENTISTRY

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** DENTAL ASSOCIATES OF LAKEWOOD
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1528557063
- **Legal business name:** DENTAL ASSOCIATES OF LAKEWOOD
- **Authorized official:** ANDRE SHIVRATTAN (CREDENTIALING SPECIALIST)
- **Authorized official phone:** (347) 579-5159

## Contact information

- **Practice address:** 6 W SPRUCE ST, LAKEWOOD, NJ 08701-5007
- **Practice address phone:** (732) 364-5100
- **Practice address fax:** (201) 927-3474
- **Mailing address:** 6 W SPRUCE ST, LAKEWOOD, NJ 08701-5007
- **Mailing address phone:** (732) 364-5100
- **Mailing address fax:** (201) 927-3474

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 22DI01842800 | NJ | Yes |

## Other

- **Enumeration date:** 05/09/2018
- **Last updated:** 05/09/2018