Provider Demographics
NPI:1932840220
Name:KIDS DENTAL SPACE, LLC
Entity Type:Organization
Organization Name:KIDS DENTAL SPACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:PATREACE
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-537-5536
Mailing Address - Street 1:8617 GOLDENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-2032
Mailing Address - Country:US
Mailing Address - Phone:301-537-5536
Mailing Address - Fax:
Practice Address - Street 1:7402 YORK RD STE 204
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7520
Practice Address - Country:US
Practice Address - Phone:301-537-5536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-02
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD046568200Medicaid
MD1326279829OtherNPI