Provider Demographics
NPI:1821495714
Name:STELLAR DENTAL OF HYATTSVILLE, LLC
Entity Type:Organization
Organization Name:STELLAR DENTAL OF HYATTSVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-853-1567
Mailing Address - Street 1:5105 GRIFFENDALE LN
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3180
Mailing Address - Country:US
Mailing Address - Phone:202-203-0230
Mailing Address - Fax:
Practice Address - Street 1:5505 SARGENT RD STE A
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-2320
Practice Address - Country:US
Practice Address - Phone:301-853-1567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14124122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty