Provider Demographics
NPI:1205252798
Name:DEARSTINE, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DEARSTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13995 TRIADELPHIA RD
Mailing Address - Street 2:
Mailing Address - City:GLENELG
Mailing Address - State:MD
Mailing Address - Zip Code:21737-9732
Mailing Address - Country:US
Mailing Address - Phone:443-812-2322
Mailing Address - Fax:
Practice Address - Street 1:8955 GUILFORD RD
Practice Address - Street 2:SUITE 240
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2651
Practice Address - Country:US
Practice Address - Phone:443-393-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-09
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02066171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist