Provider Demographics
NPI:1003167727
Name:MARYLAND DENTAL SPECIALTY GROUP
Entity Type:Organization
Organization Name:MARYLAND DENTAL SPECIALTY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SOORITA
Authorized Official - Middle Name:DVI
Authorized Official - Last Name:GOORAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-598-3951
Mailing Address - Street 1:13975 CONNECTICUT AVE
Mailing Address - Street 2:SUITE # 208
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-2921
Mailing Address - Country:US
Mailing Address - Phone:301-598-3951
Mailing Address - Fax:
Practice Address - Street 1:13975 CONNECTICUT AVE
Practice Address - Street 2:SUITE # 208
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-2921
Practice Address - Country:US
Practice Address - Phone:301-598-3951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11536122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty