Provider Demographics
NPI:1689381287
Name:STOMACARE CORPORATION
Entity Type:Organization
Organization Name:STOMACARE CORPORATION
Other - Org Name:CLARKSBURG DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANJAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODJAEV
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-505-9340
Mailing Address - Street 1:12051 CHESTNUT BRANCH WAY STE C3
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-5328
Mailing Address - Country:US
Mailing Address - Phone:301-355-4789
Mailing Address - Fax:
Practice Address - Street 1:12051 CHESTNUT BRANCH WAY STE C3
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-5328
Practice Address - Country:US
Practice Address - Phone:301-355-4789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-02
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental