Provider Demographics
NPI:1760887970
Name:HYATTSVILLE PEDIATRICE DENTISTRY
Entity Type:Organization
Organization Name:HYATTSVILLE PEDIATRICE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KESNEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUFRESNE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:240-764-5510
Mailing Address - Street 1:2970 BELCREST CENTER DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-1987
Mailing Address - Country:US
Mailing Address - Phone:240-764-5510
Mailing Address - Fax:
Practice Address - Street 1:2970 BELCREST CENTER DRIVE
Practice Address - Street 2:SUITE 105
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-1987
Practice Address - Country:US
Practice Address - Phone:240-764-5510
Practice Address - Fax:240-764-5512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD092361223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD14445OtherSTATE OF MARYLAND, DEPARTMENT OF HEALTH AND MENTAL HYGIENE, LICENSE
MD410995300Medicaid
MDD72767OtherDEPARTMENT OF HEALTH AND MENTAL HYGIENE, DIVISION OF DRUG CONTROL
DCFD2600890OtherCONTROLLED SUBSTANCE REGISTRATION CERTIFICATE, US DEPT OF JUSTICE DRUG ENFORCEME