Provider Demographics
NPI:1760858518
Name:BETHESDA PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:BETHESDA PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ARIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-654-3011
Mailing Address - Street 1:4405 E WEST HWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-4522
Mailing Address - Country:US
Mailing Address - Phone:301-654-3011
Mailing Address - Fax:301-986-1452
Practice Address - Street 1:4405 E WEST HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-4522
Practice Address - Country:US
Practice Address - Phone:301-654-3011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-17
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC8760122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty