Provider Demographics
NPI:1013093343
Name:DEITRICK, DAVID RUSH (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RUSH
Last Name:DEITRICK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 RITCHIE HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146
Mailing Address - Country:US
Mailing Address - Phone:410-647-3883
Mailing Address - Fax:410-647-0504
Practice Address - Street 1:815 RITCHIE HWY
Practice Address - Street 2:SUITE 202
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146
Practice Address - Country:US
Practice Address - Phone:410-647-3883
Practice Address - Fax:410-647-0504
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD94191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
2228OtherBLUE CROSS BLUE SHIELD
MD180400OtherUNITED CONCORDIA