Provider Demographics
NPI:1760934665
Name:DELMARVA SMILE CORNER, LLC
Entity Type:Organization
Organization Name:DELMARVA SMILE CORNER, LLC
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:410-937-3332
Mailing Address - Street 1:1112 JANICE CT.
Mailing Address - Street 2:
Mailing Address - City:JOPPA
Mailing Address - State:MD
Mailing Address - Zip Code:21085
Mailing Address - Country:US
Mailing Address - Phone:410-937-3332
Mailing Address - Fax:410-879-3701
Practice Address - Street 1:213 MARYLAND AVE.
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801
Practice Address - Country:US
Practice Address - Phone:410-937-3332
Practice Address - Fax:410-879-3701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11612122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1114251030Medicaid
MD1679683783OtherINDIVIDUAL NPI