Provider Demographics
NPI:1518610781
Name:PRESTIGE PERIODONTICS BOWIE LLC
Entity Type:Organization
Organization Name:PRESTIGE PERIODONTICS BOWIE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:301-681-4812
Mailing Address - Street 1:4201 NORTHVIEW DR STE 501
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-2674
Mailing Address - Country:US
Mailing Address - Phone:301-681-4812
Mailing Address - Fax:
Practice Address - Street 1:4201 NORTHVIEW DR STE 501
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-2674
Practice Address - Country:US
Practice Address - Phone:301-681-4812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESTIGE PERIODONTICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty