Provider Demographics
NPI:1568775880
Name:GLORIA KIDZ DENTAL LLC
Entity Type:Organization
Organization Name:GLORIA KIDZ DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAE WAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-969-9090
Mailing Address - Street 1:7951 CRAIN HWY S
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4934
Mailing Address - Country:US
Mailing Address - Phone:410-969-9090
Mailing Address - Fax:410-969-9055
Practice Address - Street 1:7951 CRAIN HWY S
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4934
Practice Address - Country:US
Practice Address - Phone:410-969-9090
Practice Address - Fax:410-969-9055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-15
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD142671223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD024168700Medicaid