1760887970 NPI number — HYATTSVILLE PEDIATRICE 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 1760887970 NPI number — HYATTSVILLE PEDIATRICE DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HYATTSVILLE PEDIATRICE 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:
1760887970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2970 BELCREST CENTER DR
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
HYATTSVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20782-1987
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-764-5510
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2970 BELCREST CENTER DRIVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
HYATTSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20782-1987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-764-5510
Provider Business Practice Location Address Fax Number:
240-764-5512
Provider Enumeration Date:
10/30/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DUFRESNE
Authorized Official First Name:
KESNEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
240-764-5510

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  09236 , 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: 14445 . This is a "STATE OF MARYLAND, DEPARTMENT OF HEALTH AND MENTAL HYGIENE, LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 410995300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: D72767 . This is a "DEPARTMENT OF HEALTH AND MENTAL HYGIENE, DIVISION OF DRUG CONTROL" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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