Provider Demographics
NPI:1548733710
Name:PARAGON DENTAL, LLC
Entity Type:Organization
Organization Name:PARAGON DENTAL, LLC
Other - Org Name:COLLEGE PARK DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YULIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUPCHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-474-8900
Mailing Address - Street 1:9009 RHODE ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-1929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9009 RHODE ISLAND AVE
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-1929
Practice Address - Country:US
Practice Address - Phone:301-474-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-09
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD111733500Medicaid