1457181331 NPI number — EXCITE DENTAL OF LAUREL

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 1457181331 NPI number — EXCITE DENTAL OF LAUREL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCITE DENTAL OF LAUREL
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:
1457181331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
820 NELL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYKESVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21784-8094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-379-5858
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3569 RUSSETT GREEN EAST
Provider Second Line Business Practice Location Address:
SUITE 104-105
Provider Business Practice Location Address City Name:
LAUREL
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-547-1999
Provider Business Practice Location Address Fax Number:
240-547-1966
Provider Enumeration Date:
08/05/2024

Additional Information

Authorized Official

Authorized Official Last Name:
MOON
Authorized Official First Name:
JAY
Authorized Official Middle Name:
SONG
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
301-379-5858

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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