Basic Information
| Provider Information | |||||||||
| NPI: | 1164156972 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SL SAMPLE DDS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10500 NORBOURNE FARM RD | ||||||||
| Address2: | |||||||||
| City: | UPPER MARLBORO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207724696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623746450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6339 ALLENTOWN RD STE E | ||||||||
| Address2: | |||||||||
| City: | CAMP SPRINGS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207482600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014492800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2022 | ||||||||
| LastUpdateDate: | 07/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | SAMPLE | ||||||||
| AuthorizedOfficialFirstName: | SHEMIKA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6623746450 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 07/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.