Provider Demographics
NPI:1760023204
Name:MYDNTST OF MAPLE LAWN LLC
Entity Type:Organization
Organization Name:MYDNTST OF MAPLE LAWN LLC
Other - Org Name:FRESH DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:RESH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-393-3930
Mailing Address - Street 1:8175 WESTSIDE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2590
Mailing Address - Country:US
Mailing Address - Phone:443-756-1011
Mailing Address - Fax:
Practice Address - Street 1:8175 WESTSIDE BLVD STE A
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2590
Practice Address - Country:US
Practice Address - Phone:443-756-1011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty