Provider Demographics
NPI:1174637185
Name:LONGMEADOW FAMILY DENTAL CARE
Entity Type:Organization
Organization Name:LONGMEADOW FAMILY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-739-1100
Mailing Address - Street 1:19638 LEITERSBURG PIKE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1438
Mailing Address - Country:US
Mailing Address - Phone:301-739-1100
Mailing Address - Fax:
Practice Address - Street 1:19638 LEITERSBURG PIKE
Practice Address - Street 2:SUITE 103
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:301-739-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14739122300000X
MD125081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty