Organization
PREMIER DENTAL GROUP PLLC
Active
Other names
Lighthouse Pediatric Dental Team
Organization subpart
No
Provider details
NPI number
Authorized official
DR. PAYAM AMIRSAYAFI (OWNER)
(617) 943-8812
Entity
Organization
Contact information
Practice address
9420 FORESTWOOD LN STE 201, MANASSAS, VA 20110-4758
(617) 943-8812
Mailing address
9420 FORESTWOOD LN STE 201, MANASSAS, VA 20110-4758
Taxonomy
Speciality
Code
Description
License number
State
1223D0004X
Dental Anesthesiology
—
—
1223P0221X
Pediatric Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1881968204
—
VA
Enumeration date
03/18/2019
Last updated
03/18/2019
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