Provider Demographics
NPI:1164156972
Name:SL SAMPLE DDS LLC
Entity Type:Organization
Organization Name:SL SAMPLE DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHEMIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:662-374-6450
Mailing Address - Street 1:10500 NORBOURNE FARM RD
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-4696
Mailing Address - Country:US
Mailing Address - Phone:662-374-6450
Mailing Address - Fax:
Practice Address - Street 1:6339 ALLENTOWN RD STE E
Practice Address - Street 2:
Practice Address - City:CAMP SPRINGS
Practice Address - State:MD
Practice Address - Zip Code:20748-2600
Practice Address - Country:US
Practice Address - Phone:301-449-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental