Provider Demographics
NPI:1265983985
Name:IB DENTAL III
Entity type:Organization
Organization Name:IB DENTAL III
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO AND PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SHEROD
Authorized Official - Last Name:DAYSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MBA
Authorized Official - Phone:202-297-1500
Mailing Address - Street 1:2970 BELCREST CENTER DR
Mailing Address - Street 2:STE. 105
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-1912
Mailing Address - Country:US
Mailing Address - Phone:301-567-5437
Mailing Address - Fax:301-567-5456
Practice Address - Street 1:2970 BELCREST CENTER DR
Practice Address - Street 2:STE. 105
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-1987
Practice Address - Country:US
Practice Address - Phone:301-567-5437
Practice Address - Fax:301-567-5456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15968122300000X
MD02372126800000X
MD18788126800000X
MD141391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty