Provider Demographics
NPI:1467849711
Name:ANNAPOLIS GREEN DENTAL LLC
Entity Type:Organization
Organization Name:ANNAPOLIS GREEN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT DESK MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVEY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:COOK
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:410-224-4500
Mailing Address - Street 1:2331 FOREST DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3868
Mailing Address - Country:US
Mailing Address - Phone:410-224-4500
Mailing Address - Fax:651-317-6283
Practice Address - Street 1:2331 FOREST DR
Practice Address - Street 2:SUITE E
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3868
Practice Address - Country:US
Practice Address - Phone:410-224-4500
Practice Address - Fax:651-317-6283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14701261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental