Provider Demographics
NPI:1417350281
Name:GOOD NEIGHBOR DENTAL
Entity Type:Organization
Organization Name:GOOD NEIGHBOR DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KYU
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:301-355-4789
Mailing Address - Street 1:12051 CHESTNUT BRANCH WAY STE C3
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-5328
Mailing Address - Country:US
Mailing Address - Phone:301-355-4789
Mailing Address - Fax:
Practice Address - Street 1:12051 CHESTNUT BRANCH WAY STE C3
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-5328
Practice Address - Country:US
Practice Address - Phone:301-355-4789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15618122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124216593OtherINDIVIDUAL NPI
1205123346OtherINDIVIDUAL NPI
1467642181OtherINDIVIDUAL NPI