Provider Demographics
NPI:1821384314
Name:EDMONDSON DENTAL CENTER FOR MARYLAND PUBLIC HEALTH, INC
Entity Type:Organization
Organization Name:EDMONDSON DENTAL CENTER FOR MARYLAND PUBLIC HEALTH, INC
Other - Org Name:PAMPERED SMILES DENTAL DAY SPA (D.D.S.)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:C.W.
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-895-5780
Mailing Address - Street 1:170 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21536-1383
Mailing Address - Country:US
Mailing Address - Phone:301-895-5780
Mailing Address - Fax:
Practice Address - Street 1:170 MILLER ST
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21536-1383
Practice Address - Country:US
Practice Address - Phone:301-895-5780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD138211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD039320700Medicaid