Provider Demographics
NPI:1083367734
Name:MY KIDS DENTAL CENTER, LLC
Entity Type:Organization
Organization Name:MY KIDS DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SACHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERS CARGILL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:240-670-4780
Mailing Address - Street 1:10801 LOCKWOOD DR STE 205
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-1563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10801 LOCKWOOD DR STE 205
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-1563
Practice Address - Country:US
Practice Address - Phone:240-670-4780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1538313481OtherINDIVIDUAL NPI