Provider Demographics
NPI:1982241626
Name:DELLA-DAVIS, MARY (LE (LICENSED ELECT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:DELLA-DAVIS
Suffix:
Gender:F
Credentials:LE (LICENSED ELECT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 SULGRAVE AVE
Mailing Address - Street 2:ATTN: VILLAGE ELECTROLYSIS
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209
Mailing Address - Country:US
Mailing Address - Phone:410-578-0033
Mailing Address - Fax:
Practice Address - Street 1:1621 SULGRAVE AVE
Practice Address - Street 2:ATTN: VILLAGE ELECTROLYSIS
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209
Practice Address - Country:US
Practice Address - Phone:410-578-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDEO1228247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other