Provider Demographics
NPI:1447769302
Name:NORTH POTOMAC DENTAL STUDIO
Entity Type:Organization
Organization Name:NORTH POTOMAC DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:
Authorized Official - Last Name:PONRAJ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-963-6300
Mailing Address - Street 1:211 MARKET ST W
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-6428
Mailing Address - Country:US
Mailing Address - Phone:301-963-6300
Mailing Address - Fax:
Practice Address - Street 1:211 MARKET ST W
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-6428
Practice Address - Country:US
Practice Address - Phone:301-963-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14719261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD=========OtherPPO