1114015468 NPI number — JULIAN CENTER FOR COMPREHENSIVE DENTISTRY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114015468 NPI number — JULIAN CENTER FOR COMPREHENSIVE DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JULIAN CENTER FOR COMPREHENSIVE 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:
1114015468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5012 DORSEY HALL DR
Provider Second Line Business Mailing Address:
STE 205
Provider Business Mailing Address City Name:
ELLICOTT CITY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21042-7711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-964-3118
Provider Business Mailing Address Fax Number:
410-964-3154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5012 DORSEY HALL DR
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
ELLICOTT CITY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21042-7711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-964-3118
Provider Business Practice Location Address Fax Number:
410-964-3154
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAMBATARO
Authorized Official First Name:
EUGENE
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
410-964-3118

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  07296 , 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)





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