1104319029 NPI number — CHARMING SMILES FAMILY DENTISTRY

Table of content: (NPI 1104319029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104319029 NPI number — CHARMING SMILES FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARMING SMILES FAMILY DENTISTRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104319029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1257
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAUREL
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20725-1257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-317-9020
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14333 LAUREL BOWIE RD STE 307
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAUREL
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20708-1183
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-317-9020
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2018

Additional Information

Authorized Official

Authorized Official Last Name:
KELLEY
Authorized Official First Name:
NATALIE
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
301-317-9020

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  14418 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 031398000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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