Provider Demographics
NPI:1386009405
Name:LUSBY DENTAL LLC
Entity Type:Organization
Organization Name:LUSBY DENTAL LLC
Other - Org Name:TIDEWATER DENTAL LUSBY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-326-4078
Mailing Address - Street 1:10025 HG TRUEMAN RD
Mailing Address - Street 2:
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657-2868
Mailing Address - Country:US
Mailing Address - Phone:410-326-4078
Mailing Address - Fax:410-326-9311
Practice Address - Street 1:10025 HG TRUEMAN ROAD
Practice Address - Street 2:
Practice Address - City:LUSBY
Practice Address - State:MD
Practice Address - Zip Code:20657
Practice Address - Country:US
Practice Address - Phone:301-862-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-16
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty