Provider Demographics
NPI:1497393219
Name:AUDUBON DENTAL CENTER OF CLINTON
Entity Type:Organization
Organization Name:AUDUBON DENTAL CENTER OF CLINTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMATHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PANTANO
Authorized Official - Suffix:
Authorized Official - Credentials:DMO
Authorized Official - Phone:301-856-1122
Mailing Address - Street 1:8918 WOODYARD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735
Mailing Address - Country:US
Mailing Address - Phone:301-856-1122
Mailing Address - Fax:301-856-1759
Practice Address - Street 1:8918 WOODYARD RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735
Practice Address - Country:US
Practice Address - Phone:301-856-1122
Practice Address - Fax:301-856-1759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD049843200Medicaid