Provider Demographics
NPI:1396903704
Name:COSMETIC SMILE AND DENTURE TECHNOLOGY CONSULTANTS LLC
Entity type:Organization
Organization Name:COSMETIC SMILE AND DENTURE TECHNOLOGY CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSLYN
Authorized Official - Middle Name:ROXANNA
Authorized Official - Last Name:ROBINSON-KELLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-433-9656
Mailing Address - Street 1:PO BOX 39395
Mailing Address - Street 2:
Mailing Address - City:BALTO
Mailing Address - State:MD
Mailing Address - Zip Code:21212-6395
Mailing Address - Country:US
Mailing Address - Phone:410-433-9656
Mailing Address - Fax:
Practice Address - Street 1:9199 REISTERSTOWN ROAD
Practice Address - Street 2:SUITE 203A
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117
Practice Address - Country:US
Practice Address - Phone:410-433-9656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD108481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7552840Medicaid