Provider Demographics
NPI:1164005419
Name:BETHESDA ORTHODONTIC SPECIALIST
Entity Type:Organization
Organization Name:BETHESDA ORTHODONTIC SPECIALIST
Other - Org Name:BETHESDA DENTAL SPECIALTIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-654-3011
Mailing Address - Street 1:4405 E WEST HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-4532
Mailing Address - Country:US
Mailing Address - Phone:301-654-3011
Mailing Address - Fax:
Practice Address - Street 1:4405 E WEST HWY STE 102
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-4532
Practice Address - Country:US
Practice Address - Phone:301-654-3011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-04
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty