Provider Demographics
NPI:1932266335
Name:FUSION DENTAL
Entity Type:Organization
Organization Name:FUSION DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BOB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-645-1344
Mailing Address - Street 1:2992 WALDORF MARKETPLACE
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603
Mailing Address - Country:US
Mailing Address - Phone:301-645-1344
Mailing Address - Fax:301-645-4654
Practice Address - Street 1:2992 WALDORF MARKETPLACE
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603
Practice Address - Country:US
Practice Address - Phone:301-645-1344
Practice Address - Fax:301-645-4654
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FUSION DENTAL, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-03
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty