Basic Information
Provider Information | |||||||||
NPI: | 1417323288 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DIMENSIONS HEALTHCARE ASSOCIATES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3001 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | CHEVERLY | ||||||||
State: | MD | ||||||||
PostalCode: | 207851189 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016183655 | ||||||||
FaxNumber: | 3016183697 | ||||||||
Practice Location | |||||||||
Address1: | 5001 SILVER HILL RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SUITLAND | ||||||||
State: | MD | ||||||||
PostalCode: | 207465209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016182273 | ||||||||
FaxNumber: | 3016183697 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2015 | ||||||||
LastUpdateDate: | 08/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WALLINGTON | ||||||||
AuthorizedOfficialFirstName: | DONNA | ||||||||
AuthorizedOfficialMiddleName: | Y. | ||||||||
AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3016183655 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DIMENSIONS HEALTH CORPORATION | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D57645 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 090782102 | 05 | MD |   | MEDICAID | 405690600 | 05 | MD |   | MEDICAID |