Provider Demographics
NPI:1740722339
Name:MARYLAND PERIODONTICS
Entity type:Organization
Organization Name:MARYLAND PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:LOAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-856-1200
Mailing Address - Street 1:7902 OLD BRANCH AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-1646
Mailing Address - Country:US
Mailing Address - Phone:301-856-1200
Mailing Address - Fax:301-868-1947
Practice Address - Street 1:7902 OLD BRANCH AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-1646
Practice Address - Country:US
Practice Address - Phone:301-856-1200
Practice Address - Fax:301-868-1947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11360261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1104066257OtherNATIONAL PROVIDER ID