Provider Demographics
NPI:1033490263
Name:ANTIETAM ORTHODONTICS
Entity Type:Organization
Organization Name:ANTIETAM ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:THOMOPULOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MDS
Authorized Official - Phone:301-733-1552
Mailing Address - Street 1:322 E ANTIETAM ST
Mailing Address - Street 2:SUITE103
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5794
Mailing Address - Country:US
Mailing Address - Phone:301-733-1552
Mailing Address - Fax:301-733-1553
Practice Address - Street 1:322 E ANTIETAM ST
Practice Address - Street 2:SUITE103
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5794
Practice Address - Country:US
Practice Address - Phone:301-733-1552
Practice Address - Fax:301-733-1553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty