Provider Demographics
NPI:1922533579
Name:SPA CREEK DENTAL OF MD LLC
Entity Type:Organization
Organization Name:SPA CREEK DENTAL OF MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:757-330-0766
Mailing Address - Street 1:185 ADMIRAL COCHRANE DR
Mailing Address - Street 2:SUITE 117
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7493
Mailing Address - Country:US
Mailing Address - Phone:757-330-0766
Mailing Address - Fax:
Practice Address - Street 1:185 ADMIRAL COCHRANE DR
Practice Address - Street 2:SUITE 117
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7493
Practice Address - Country:US
Practice Address - Phone:757-330-0766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty