Provider Demographics
NPI:1760760367
Name:MAYO DENTAL LLC
Entity Type:Organization
Organization Name:MAYO DENTAL LLC
Other - Org Name:PUNEETA KEER
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTAL PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:PUNEETA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:410-956-6626
Mailing Address - Street 1:55 MAYO RD STE 1
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-1805
Mailing Address - Country:US
Mailing Address - Phone:410-956-6626
Mailing Address - Fax:877-310-6316
Practice Address - Street 1:55 MAYO RD STE 1
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-1805
Practice Address - Country:US
Practice Address - Phone:410-956-6626
Practice Address - Fax:877-310-6316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-30
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13264261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD012378100Medicaid