Provider Demographics
NPI:1073904512
Name:FAMILY DENTISTRY OF BUCKEYSTOWN PIKE
Entity Type:Organization
Organization Name:FAMILY DENTISTRY OF BUCKEYSTOWN PIKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-695-0909
Mailing Address - Street 1:5732 BUCKEYSTOWN PIKE STE 26
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-5214
Mailing Address - Country:US
Mailing Address - Phone:301-695-0909
Mailing Address - Fax:301-695-8133
Practice Address - Street 1:5732 BUCKEYSTOWN PIKE STE 26
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-5214
Practice Address - Country:US
Practice Address - Phone:301-695-0909
Practice Address - Fax:301-695-8133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13430122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD025946200Medicaid