Provider Demographics
NPI:1205297546
Name:PROVIDENCE DENTAL SPECIALISTS
Entity type:Organization
Organization Name:PROVIDENCE DENTAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-858-8377
Mailing Address - Street 1:1215 ANNAPOLIS RD STE 205
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1346
Mailing Address - Country:US
Mailing Address - Phone:443-858-8377
Mailing Address - Fax:
Practice Address - Street 1:1215 ANNAPOLIS RD STE 205
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1346
Practice Address - Country:US
Practice Address - Phone:443-858-8377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-15
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16121261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental