Provider Demographics
NPI:1710299268
Name:DIVINE DENTAL LLC
Entity Type:Organization
Organization Name:DIVINE DENTAL LLC
Other - Org Name:BROOKLYN PARK DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARYELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESROCHERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-789-5228
Mailing Address - Street 1:4801 RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21225-3045
Mailing Address - Country:US
Mailing Address - Phone:410-789-5228
Mailing Address - Fax:410-789-2162
Practice Address - Street 1:4801 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-3045
Practice Address - Country:US
Practice Address - Phone:410-789-5228
Practice Address - Fax:410-789-2162
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINE DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-12
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD70691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty