Provider Demographics
NPI:1861824104
Name:LGM DDS LLC
Entity Type:Organization
Organization Name:LGM DDS LLC
Other - Org Name:PEARL SMILES DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MEHRET
Authorized Official - Middle Name:
Authorized Official - Last Name:GOITOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-799-1793
Mailing Address - Street 1:6020 MEADOW RDG CTR DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-6088
Mailing Address - Country:US
Mailing Address - Phone:410-799-1794
Mailing Address - Fax:410-799-1794
Practice Address - Street 1:6020 MEADOW RDG CTR DR
Practice Address - Street 2:SUITE A
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6088
Practice Address - Country:US
Practice Address - Phone:410-799-1794
Practice Address - Fax:410-799-1794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-08
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD146101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1912215856OtherINDIVIDUAL NPI NUMBER
DC04607880Medicaid