Provider Demographics
NPI:1912301201
Name:JOHN, ORVILLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ORVILLE
Middle Name:
Last Name:JOHN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 CRAIN HWY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-5204
Mailing Address - Country:US
Mailing Address - Phone:301-870-3966
Mailing Address - Fax:
Practice Address - Street 1:6620 CRAIN HWY
Practice Address - Street 2:SUITE 204
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5204
Practice Address - Country:US
Practice Address - Phone:301-870-3966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD7066122300000X
DC3614122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU24571Medicare UPIN