1760887970 NPI number — HYATTSVILLE PEDIATRICE DENTISTRY

Table of content: (NPI 1760887970)

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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