Provider Demographics
NPI:1770998247
Name:WHEATON MALL DENTAL LLP
Entity type:Organization
Organization Name:WHEATON MALL DENTAL LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSTISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-933-9300
Mailing Address - Street 1:11160 VEIRS MILL RD SPC 168
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MD
Mailing Address - Zip Code:20902-5913
Mailing Address - Country:US
Mailing Address - Phone:410-933-9300
Mailing Address - Fax:
Practice Address - Street 1:11160 VEIRS MILL RD SPC 168
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MD
Practice Address - Zip Code:20902-5913
Practice Address - Country:US
Practice Address - Phone:410-933-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty