Provider Demographics
NPI:1740412030
Name:CHURCHVILLE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:CHURCHVILLE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NAHID
Authorized Official - Middle Name:Z
Authorized Official - Last Name:SHAHRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-838-5776
Mailing Address - Street 1:1402 E CHURCHVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4708
Mailing Address - Country:US
Mailing Address - Phone:410-838-5776
Mailing Address - Fax:410-879-3701
Practice Address - Street 1:1402 E CHURCHVILLE RD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4708
Practice Address - Country:US
Practice Address - Phone:410-838-5776
Practice Address - Fax:410-879-3701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2012-03-12
Deactivation Date:2009-09-24
Deactivation Code:
Reactivation Date:2012-03-12
Provider Licenses
StateLicense IDTaxonomies
MD116121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty