Provider Demographics
NPI:1891043006
Name:CPDG-AM
Entity Type:Organization
Organization Name:CPDG-AM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAKAN
Authorized Official - Middle Name:OMER
Authorized Official - Last Name:KOYMEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:410-248-3384
Mailing Address - Street 1:7556 TEAGUE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-1213
Mailing Address - Country:US
Mailing Address - Phone:410-799-0780
Mailing Address - Fax:410-799-0781
Practice Address - Street 1:7556 TEAGUE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:HANOVER
Practice Address - State:MD
Practice Address - Zip Code:21076-1213
Practice Address - Country:US
Practice Address - Phone:410-799-0780
Practice Address - Fax:410-799-0781
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESAPEAKE PEDIATRIC DENTAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-17
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD127701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD036344800Medicaid
MD022999700Medicaid
MD026120300Medicaid
MD9200608Medicaid
MD008494860Medicaid