Provider Demographics
NPI:1356164503
Name:GERONIMO, JOSE JOSHUA (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSE JOSHUA
Middle Name:
Last Name:GERONIMO
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 1:1602 HEMPSTEAD CT
Mailing Address - Street 2:
Mailing Address - City:JOPPA
Mailing Address - State:MD
Mailing Address - Zip Code:21085-5429
Mailing Address - Country:US
Mailing Address - Phone:410-804-2401
Mailing Address - Fax:
Practice Address - Street 1:2717 HAMMONDS FERRY RD
Practice Address - Street 2:
Practice Address - City:HALETHORPE
Practice Address - State:MD
Practice Address - Zip Code:21227-3100
Practice Address - Country:US
Practice Address - Phone:410-242-5012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD183461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice