Provider Demographics
NPI:1275927089
Name:RIVERSIDE DENTAL AT WATER'S EDGE LLC
Entity Type:Organization
Organization Name:RIVERSIDE DENTAL AT WATER'S EDGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NEELU
Authorized Official - Middle Name:
Authorized Official - Last Name:MILAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-272-1535
Mailing Address - Street 1:111 BATA BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:BELCAMP
Mailing Address - State:MD
Mailing Address - Zip Code:21017-1427
Mailing Address - Country:US
Mailing Address - Phone:410-272-1535
Mailing Address - Fax:410-272-0242
Practice Address - Street 1:111 BATA BLVD STE D
Practice Address - Street 2:
Practice Address - City:BELCAMP
Practice Address - State:MD
Practice Address - Zip Code:21017-1427
Practice Address - Country:US
Practice Address - Phone:410-272-1535
Practice Address - Fax:410-272-0242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD38111122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty