Provider Demographics
NPI:1013596964
Name:ORTHO SUITE LLC
Entity Type:Organization
Organization Name:ORTHO SUITE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-302-5146
Mailing Address - Street 1:5642 SHIELDS DR
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-3573
Mailing Address - Country:US
Mailing Address - Phone:301-363-9026
Mailing Address - Fax:
Practice Address - Street 1:5642 SHIELDS DR
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-3573
Practice Address - Country:US
Practice Address - Phone:301-363-9026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty