Basic Information
| Provider Information | |||||||||
| NPI: | 1649717638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAUREL LAKES PEDIATRIC DENTISTRY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAUREL LAKES PEDIATRIC DENTISTRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 CHURCH ST | ||||||||
| Address2: | SUITE 2210 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372192310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159882627 | ||||||||
| FaxNumber: | 6318577860 | ||||||||
| Practice Location | |||||||||
| Address1: | 13964 BALTIMORE AVE | ||||||||
| Address2: | SUITE C6 | ||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2022760649 | ||||||||
| FaxNumber: | 6318577860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2017 | ||||||||
| LastUpdateDate: | 07/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | ANTIONETTE | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2022760649 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 13970 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 13970 | 01 | MD | DENTAL LICENSE | OTHER |