Provider Demographics
NPI:1376065193
Name:SUPER KIDS TEETH LLC
Entity Type:Organization
Organization Name:SUPER KIDS TEETH LLC
Other - Org Name:SEVERN PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SOE
Authorized Official - Middle Name:T
Authorized Official - Last Name:MON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-995-8000
Mailing Address - Street 1:2288 BLUE WATER BLVD STE 328
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-3309
Mailing Address - Country:US
Mailing Address - Phone:410-995-8000
Mailing Address - Fax:
Practice Address - Street 1:2288 BLUE WATER BLVD STE 328
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-3309
Practice Address - Country:US
Practice Address - Phone:410-995-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD59291Medicaid