Provider Demographics
NPI:1699030478
Name:GREENBELT SMILES, LLC
Entity Type:Organization
Organization Name:GREENBELT SMILES, LLC
Other - Org Name:MARTHA BUSTILLO, D.M.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DMD
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:301-345-2222
Mailing Address - Street 1:7221 HANOVER PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2022
Mailing Address - Country:US
Mailing Address - Phone:301-345-2222
Mailing Address - Fax:301-345-1682
Practice Address - Street 1:7221 HANOVER PKWY STE A
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2022
Practice Address - Country:US
Practice Address - Phone:301-345-2222
Practice Address - Fax:301-345-1682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD122001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty