Provider Demographics
NPI:1326745845
Name:SIGNATURE DENTAL CENTER
Entity Type:Organization
Organization Name:SIGNATURE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NAYUDU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-902-1256
Mailing Address - Street 1:130 THOMAS JOHNSON DR STE 1
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4583
Mailing Address - Country:US
Mailing Address - Phone:240-831-6789
Mailing Address - Fax:
Practice Address - Street 1:130 THOMAS JOHNSON DR STE 1
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4583
Practice Address - Country:US
Practice Address - Phone:240-831-6789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD85340200Medicaid