1649717638 NPI number — LAUREL LAKES PEDIATRIC DENTISTRY, LLC

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 1649717638 NPI number — LAUREL LAKES PEDIATRIC DENTISTRY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAUREL LAKES PEDIATRIC DENTISTRY, LLC
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:
6
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:
1649717638
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 CHURCH ST
Provider Second Line Business Mailing Address:
SUITE 2210
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37219-2310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-988-2627
Provider Business Mailing Address Fax Number:
631-857-7860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13964 BALTIMORE AVE
Provider Second Line Business Practice Location Address:
SUITE C6
Provider Business Practice Location Address City Name:
LAUREL
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-276-0649
Provider Business Practice Location Address Fax Number:
631-857-7860
Provider Enumeration Date:
01/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
ANTIONETTE
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
202-276-0649

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  13970 , 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: 13970 . This is a "DENTAL LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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