Provider First Line Business Practice Location Address: 
650 WEST BALTIMORE STREET
    Provider Second Line Business Practice Location Address: 
UNIVERSITY OF MARYLAND DENTAL SCHOOL
    Provider Business Practice Location Address City Name: 
BALTIMORE
    Provider Business Practice Location Address State Name: 
MD
    Provider Business Practice Location Address Postal Code: 
21201
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
410-706-8110
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/24/2014