Provider Demographics
NPI:1093412546
Name:ELDERSBURG PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:ELDERSBURG PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SU
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-609-7770
Mailing Address - Street 1:1643 LIBERTY RD STE 103
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6545
Mailing Address - Country:US
Mailing Address - Phone:443-609-7770
Mailing Address - Fax:
Practice Address - Street 1:1643 LIBERTY RD STE 103
Practice Address - Street 2:
Practice Address - City:SYKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21784-6545
Practice Address - Country:US
Practice Address - Phone:443-609-7770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty