Provider Demographics
NPI:1083004519
Name:DIAMOND DENTAL OF OWINGS MILLS, LLC
Entity Type:Organization
Organization Name:DIAMOND DENTAL OF OWINGS MILLS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-394-2273
Mailing Address - Street 1:9419 COMMON BROOK RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-7536
Mailing Address - Country:US
Mailing Address - Phone:443-394-2273
Mailing Address - Fax:443-394-3450
Practice Address - Street 1:9419 COMMON BROOK RD
Practice Address - Street 2:SUITE 210
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-7536
Practice Address - Country:US
Practice Address - Phone:443-394-2273
Practice Address - Fax:443-394-3450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD134331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty