Provider Demographics
NPI:1710473731
Name:MARLBOROUGH VILLAGE PEDIATRIC DENTAL
Entity Type:Organization
Organization Name:MARLBOROUGH VILLAGE PEDIATRIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:JOHNSTON
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-280-0968
Mailing Address - Street 1:14300 RIDGE VIEW LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-6278
Mailing Address - Country:US
Mailing Address - Phone:443-280-0968
Mailing Address - Fax:
Practice Address - Street 1:5098 BROWN STATION RD STE 260
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-9124
Practice Address - Country:US
Practice Address - Phone:240-326-3738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD147041223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD71150100Medicaid