Basic Information
| Provider Information | |||||||||
| NPI: | 1710227863 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DENTAL ASSOCIATES OF GREATER MARYLAND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6339 ALLENTOWN RD STE E | ||||||||
| Address2: | |||||||||
| City: | TEMPLE HILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207482600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014492800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6339 ALLENTOWN RD STE E | ||||||||
| Address2: | |||||||||
| City: | TEMPLE HILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207482600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014492800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2013 | ||||||||
| LastUpdateDate: | 02/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | PARK | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4109978383 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 13144 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 020167700 | 05 | MD | MEDICAID |