Provider Demographics
NPI:1508254145
Name:SG DENTAL ASSOCIATES OF MARYLAND LLC
Entity Type:Organization
Organization Name:SG DENTAL ASSOCIATES OF MARYLAND LLC
Other - Org Name:ASPEN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER RELATIONS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-464-6000
Mailing Address - Street 1:1730 MASSEY BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6973
Mailing Address - Country:US
Mailing Address - Phone:301-800-7041
Mailing Address - Fax:240-420-5497
Practice Address - Street 1:1730 MASSEY BLVD
Practice Address - Street 2:STE 106
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6973
Practice Address - Country:US
Practice Address - Phone:301-800-7041
Practice Address - Fax:240-420-5497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD156711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty