Provider Demographics
NPI:1710940911
Name:FOREST HILL FAMILY & COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:FOREST HILL FAMILY & COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:EBNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-838-6630
Mailing Address - Street 1:2 COLGATE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-2652
Mailing Address - Country:US
Mailing Address - Phone:410-838-6630
Mailing Address - Fax:410-838-2616
Practice Address - Street 1:2 COLGATE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-2652
Practice Address - Country:US
Practice Address - Phone:410-838-6630
Practice Address - Fax:410-838-2616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09735122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty