Provider Demographics
NPI:1619360765
Name:POTOMACDENTALCENTER
Entity Type:Organization
Organization Name:POTOMACDENTALCENTER
Other - Org Name:NO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELENIR
Authorized Official - Middle Name:G
Authorized Official - Last Name:BERNARDES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-881-5020
Mailing Address - Street 1:11404 OLD GEORGETOWN RD
Mailing Address - Street 2:201
Mailing Address - City:NORTH BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2865
Mailing Address - Country:US
Mailing Address - Phone:301-881-5020
Mailing Address - Fax:301-881-5030
Practice Address - Street 1:11404 OLD GEORGETOWN RD
Practice Address - Street 2:201
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-2865
Practice Address - Country:US
Practice Address - Phone:301-881-5020
Practice Address - Fax:301-881-5030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty