Provider Demographics
NPI:1043694623
Name:FREDERICK KIDDS PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:FREDERICK KIDDS PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:D'AUDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-202-5041
Mailing Address - Street 1:211 SHOREBIRD ST STE B
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-1963
Mailing Address - Country:US
Mailing Address - Phone:301-202-5041
Mailing Address - Fax:
Practice Address - Street 1:211 SHOREBIRD ST STE B
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-1963
Practice Address - Country:US
Practice Address - Phone:301-202-5041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD140791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1194880633OtherINDIVIDUAL NPI