Provider Demographics
NPI:1437550761
Name:EASTERN AVENUE DENTAL, LLC
Entity Type:Organization
Organization Name:EASTERN AVENUE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SINHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-335-7771
Mailing Address - Street 1:PO BOX B
Mailing Address - Street 2:
Mailing Address - City:CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:21027-0020
Mailing Address - Country:US
Mailing Address - Phone:410-335-7771
Mailing Address - Fax:
Practice Address - Street 1:12412 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21220
Practice Address - Country:US
Practice Address - Phone:410-335-7771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-05
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12853122300000X
MD13144122300000X
MD14921122300000X
MD15012122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty