Provider Demographics
NPI:1295279024
Name:PGN DENTAL LLC
Entity type:Organization
Organization Name:PGN DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RECEPTION/FINANCIAL
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEREZOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-627-6687
Mailing Address - Street 1:14420 OLD MILL RD STE 101
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3096
Mailing Address - Country:US
Mailing Address - Phone:301-627-6686
Mailing Address - Fax:
Practice Address - Street 1:14420 OLD MILL RD STE 101
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3096
Practice Address - Country:US
Practice Address - Phone:301-627-6686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD148711223G0001X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty