Provider Demographics
NPI:1376820654
Name:CHILDREN'S DENTISTRY AT ODENTON
Entity Type:Organization
Organization Name:CHILDREN'S DENTISTRY AT ODENTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:SEVILLA
Authorized Official - Last Name:GUEVARA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:410-672-1100
Mailing Address - Street 1:1215 ANNAPOLIS RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1344
Mailing Address - Country:US
Mailing Address - Phone:410-672-1100
Mailing Address - Fax:410-672-1107
Practice Address - Street 1:1215 ANNAPOLIS RD
Practice Address - Street 2:SUITE 106
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1344
Practice Address - Country:US
Practice Address - Phone:410-672-1100
Practice Address - Fax:410-672-1107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD123741223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD135705100Medicaid