Provider Demographics
NPI:1811571318
Name:MOCO PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:MOCO PEDIATRIC DENTISTRY LLC
Other - Org Name:PLOVER PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:HAE JIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:240-642-3161
Mailing Address - Street 1:11325 SEVEN LOCKS RD STE 250
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-3269
Mailing Address - Country:US
Mailing Address - Phone:240-642-3161
Mailing Address - Fax:240-642-3162
Practice Address - Street 1:11325 SEVEN LOCKS RD STE 250
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-3269
Practice Address - Country:US
Practice Address - Phone:406-423-1612
Practice Address - Fax:240-642-3161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-11
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty