Provider Demographics
NPI:1689283681
Name:MY ELLICOTT CITY DENTIST LLC
Entity Type:Organization
Organization Name:MY ELLICOTT CITY DENTIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CYRUS
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLAFI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-480-2000
Mailing Address - Street 1:10050 BALTIMORE NATIONAL PIKE STE F110
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-3668
Mailing Address - Country:US
Mailing Address - Phone:410-480-2000
Mailing Address - Fax:
Practice Address - Street 1:10050 BALTIMORE NATIONAL PIKE STE F110
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3668
Practice Address - Country:US
Practice Address - Phone:410-480-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-26
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty