Provider Demographics
NPI:1558645663
Name:FUSION DENTAL
Entity Type:Organization
Organization Name:FUSION DENTAL
Other - Org Name:FUSION DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PC PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-843-9330
Mailing Address - Street 1:1137 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-7934
Mailing Address - Country:US
Mailing Address - Phone:410-795-7484
Mailing Address - Fax:
Practice Address - Street 1:5959 EXCHANGE DRIVE
Practice Address - Street 2:SUITE 116
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784
Practice Address - Country:US
Practice Address - Phone:410-795-7484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FUSION DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10965122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty