Provider Demographics
NPI:1811602907
Name:DENTRUST DENTAL MARYLAND, P.A.
Entity type:Organization
Organization Name:DENTRUST DENTAL MARYLAND, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTALING
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-927-5000
Mailing Address - Street 1:2799 ROSE ST BLDG 685
Mailing Address - Street 2:
Mailing Address - City:FORT GEORGE G MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-5140
Mailing Address - Country:US
Mailing Address - Phone:267-927-5000
Mailing Address - Fax:
Practice Address - Street 1:2799 ROSE ST BLDG 685
Practice Address - Street 2:
Practice Address - City:FORT GEORGE G MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5140
Practice Address - Country:US
Practice Address - Phone:267-927-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTRUST DENTAL MARYLAND, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-23
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD10988OtherDENTISTRY