Provider Demographics
NPI:1093094476
Name:MONTGOMERY COUNTY MARYLAND GOVERNMENT
Entity Type:Organization
Organization Name:MONTGOMERY COUNTY MARYLAND GOVERNMENT
Other - Org Name:DHHS DENTAL PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:FIRESTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-777-2500
Mailing Address - Street 1:101 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-2503
Mailing Address - Country:US
Mailing Address - Phone:240-777-2500
Mailing Address - Fax:
Practice Address - Street 1:1335 PICCARD DR
Practice Address - Street 2:1ST FLOOR DENTAL SUITE
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-4359
Practice Address - Country:US
Practice Address - Phone:240-777-1820
Practice Address - Fax:240-777-1080
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONTGOMERY COUNTY MARYLAND GOVERNMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-16
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD420870600Medicaid