1649597824 NPI number — CHESAPEAKE CONTEMPORARY DENTISTRY, P.A.

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 1649597824 NPI number — CHESAPEAKE CONTEMPORARY DENTISTRY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHESAPEAKE CONTEMPORARY DENTISTRY, P.A.
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:
1649597824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1308 BUSINESS CENTER WAY
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
EDGEWOOD
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21040-1504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-679-2790
Provider Business Mailing Address Fax Number:
410-679-4207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1308 BUSINESS CENTER WAY
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
EDGEWOOD
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21040-1504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-679-2790
Provider Business Practice Location Address Fax Number:
410-679-4207
Provider Enumeration Date:
04/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MOOMAW
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
EDWIN
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
410-679-2790

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  6960 , 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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