Provider Demographics
NPI:1790920759
Name:IMBACH, RICHARD MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MARK
Last Name:IMBACH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4809 LEEDS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227
Mailing Address - Country:US
Mailing Address - Phone:410-242-1112
Mailing Address - Fax:410-418-9579
Practice Address - Street 1:4809 LEEDS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21227
Practice Address - Country:US
Practice Address - Phone:410-242-1112
Practice Address - Fax:410-418-9579
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06979122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist