Provider Demographics
NPI:1629583943
Name:VANGUARD ORTHODONTICS LLC
Entity Type:Organization
Organization Name:VANGUARD ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BYRON
Authorized Official - Last Name:BONEBREAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-381-1077
Mailing Address - Street 1:12240 PLEASANT SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-9647
Mailing Address - Country:US
Mailing Address - Phone:443-956-5814
Mailing Address - Fax:
Practice Address - Street 1:8191 MAPLE LAWN BLVD STE E
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2535
Practice Address - Country:US
Practice Address - Phone:410-381-1077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14232261QD0000X
MD6368261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental