Provider Demographics
NPI:1962663203
Name:POST OFFICE LAKE DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:POST OFFICE LAKE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE CONTACT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAMEASA
Authorized Official - Middle Name:LAVONNE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-870-7077
Mailing Address - Street 1:603 POST OFFICE RD STE 208
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-1914
Mailing Address - Country:US
Mailing Address - Phone:301-870-7077
Mailing Address - Fax:301-843-8030
Practice Address - Street 1:603 POST OFFICE RD STE 208
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-1914
Practice Address - Country:US
Practice Address - Phone:301-870-7077
Practice Address - Fax:301-843-8030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD108571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4133552 00Medicaid
MD776024860Medicaid
MD775954160Medicaid