Provider Demographics
NPI:1710438601
Name:AGE ONE PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:AGE ONE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS-CONERLY
Authorized Official - Suffix:
Authorized Official - Credentials:DENTIST
Authorized Official - Phone:989-714-4470
Mailing Address - Street 1:14012 WAGON WAY
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906
Mailing Address - Country:US
Mailing Address - Phone:989-714-4470
Mailing Address - Fax:
Practice Address - Street 1:8611 2ND AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3372
Practice Address - Country:US
Practice Address - Phone:989-714-4470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD141261223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty