Provider Demographics
NPI:1679628846
Name:MAYOR AND CITY COUNCIL OF BALTIMORE
Entity Type:Organization
Organization Name:MAYOR AND CITY COUNCIL OF BALTIMORE
Other - Org Name:ORAL HEALTH SERVICES DRUID HILL
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING & REVENUE MGR.
Authorized Official - Prefix:
Authorized Official - First Name:TYRONE
Authorized Official - Middle Name:ALONZO
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-739-3253
Mailing Address - Street 1:1001 E FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4715
Mailing Address - Country:US
Mailing Address - Phone:443-984-2621
Mailing Address - Fax:
Practice Address - Street 1:1515 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-1735
Practice Address - Country:US
Practice Address - Phone:410-396-4501
Practice Address - Fax:410-962-8726
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAYOR AND CITY COUNCIL OF BALTIMORE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-25
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30000559251K00000X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD416947600Medicaid