| Name: | Premier One Implant Centers, Inc. |
| Jurisdiction: | Rhode Island |
| Entity type: | Domestic Profit Corporation |
| Status: | Revoked Entity |
| Date of Organization in Rhode Island: | 20 Dec 1983 (41 years ago) |
| Date of Dissolution: | 12 Sep 2023 (a year ago) |
| Date of Status Change: | 12 Sep 2023 (a year ago) |
| Identification Number: | 000001558 |
| Principal Address: | 103 COMMONWEALTH AVENUE, ATTLEBORO FALLS, MA, 02763, USA |
| Purpose: | PRACTICE OF DENTISTRY AND ORAL SURGEONS |
| NAICS: | 621210 - Offices of Dentists |
| Historical names: |
Attleboro-Cumberland Oral Surgeons, Inc. |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1972545481 | 2006-06-11 | 2008-01-02 | 3353 MENDON RD, CUMBERLAND, RI, 02864, US | 3353 MENDON RD, CUMBERLAND, RI, 02864, US | |||||||||||||||||||||||||||||||||||
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| Phone | +1 401-658-2224 |
| Fax | 4016580039 |
Authorized person
| Name | JOHN F BIERNACKI |
| Role | PARTNER |
| Phone | 4016582224 |
Taxonomy
| Taxonomy Code | 1223S0112X - Oral and Maxillofacial Surgery (Dentist) |
| License Number | 01614 |
| State | RI |
| Is Primary | Yes |
| Taxonomy Code | 1223S0112X - Oral and Maxillofacial Surgery (Dentist) |
| License Number | 012100 |
| State | MA |
| Is Primary | No |
Other Provider Identifiers
| Issuer | RIBC |
| Number | 86509 |
| Issuer | BCBS MA |
| Number | X10578 |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| ATTLEBORO-CUMBERLAND ORAL SURGEONS, INC. SH 401-K CT PSP | 2015 | 050404003 | 2016-10-05 | ATTLEBORO-CUMBERLAND ORAL SURGEONS, INC. | 14 | |||||||||||||||||||||
|
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| Role | Plan administrator |
| Date | 2016-10-05 |
| Name of individual signing | JOHN BIERNACKI |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 002 |
| Effective date of plan | 1984-01-01 |
| Business code | 621210 |
| Plan sponsor’s address | 3353 MENDON ROAD, CUMBERLAND, RI, 02864 |
Signature of
| Role | Plan administrator |
| Date | 2016-01-06 |
| Name of individual signing | JOHN BIERNACKI |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 002 |
| Effective date of plan | 1984-01-01 |
| Business code | 621210 |
| Plan sponsor’s address | 3353 MENDON ROAD, CUMBERLAND, RI, 02864 |
Signature of
| Role | Plan administrator |
| Date | 2015-04-07 |
| Name of individual signing | JOHN BIERNACKI |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| JOHN S. DIBONA, ESQ. | Agent | 78 KENWOOD STREET, CRANSTON, RI, 02907, USA |
| Name | Role | Address |
|---|---|---|
| MARK D SCHENKMAN | PRESIDENT | 16232 1ST AVENUE PHOENIX, AZ 85045 USA |
| Type | Date | Old Value | New Value |
|---|---|---|---|
| Name Change | 2021-01-01 | Attleboro-Cumberland Oral Surgeons, Inc. | Premier One Implant Centers, Inc. |
| Number | Name | File Date |
|---|---|---|
| 202341440970 | Revocation Certificate For Failure to File the Annual Report for the Year | 2023-09-12 |
| 202337975910 | Revocation Notice For Failure to File An Annual Report | 2023-06-19 |
| 202215534710 | Annual Report | 2022-04-18 |
| 202190144100 | Annual Report | 2021-02-04 |
| 202078495300 | Articles of Amendment | 2020-12-03 |
| 202038309320 | Statement of Change of Registered/Resident Agent Office | 2020-04-22 |
| 202038297690 | Statement of Change of Registered/Resident Agent Office | 2020-04-22 |
| 202033703150 | Annual Report | 2020-02-03 |
| 201997524540 | Annual Report | 2019-06-17 |
| 201860310690 | Annual Report | 2018-03-15 |
Date of last update: 05 Oct 2024
Sources: Rhode Island Department of State
