Provider Demographics
NPI:1669687802
Name:SPECTRUM DENTAL SERVICES P A
Entity Type:Organization
Organization Name:SPECTRUM DENTAL SERVICES P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:R
Authorized Official - Last Name:TURNER JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-541-4432
Mailing Address - Street 1:200 E 33RD STREET
Mailing Address - Street 2:SUITE 284
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218
Mailing Address - Country:US
Mailing Address - Phone:410-235-0062
Mailing Address - Fax:
Practice Address - Street 1:200 EAST 33RD STREET
Practice Address - Street 2:SUITE 284
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218
Practice Address - Country:US
Practice Address - Phone:410-235-0062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
MD76951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0004418OtherDORAL DENTAL
MD2009OtherCAREFIRST BLUECROSS
MD000952871OtherUNITED CONCORDIA
MD261864800Medicaid