Provider Demographics
NPI:1649717638
Name:LAUREL LAKES PEDIATRIC DENTISTRY, LLC
Entity type:Organization
Organization Name:LAUREL LAKES PEDIATRIC DENTISTRY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTIONETTE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-276-0649
Mailing Address - Street 1:401 CHURCH ST
Mailing Address - Street 2:SUITE 2210
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-2310
Mailing Address - Country:US
Mailing Address - Phone:615-988-2627
Mailing Address - Fax:631-857-7860
Practice Address - Street 1:13964 BALTIMORE AVE
Practice Address - Street 2:SUITE C6
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707
Practice Address - Country:US
Practice Address - Phone:202-276-0649
Practice Address - Fax:631-857-7860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-27
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD139701223P0221X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD13970OtherDENTAL LICENSE
MDFW4394716OtherDEA