MEDICARE: DENTAL ONE ASSOCIATES FREDERICK CROSSING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist		MD

General Provider Information

NPI Number	:	1093137242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL ONE ASSOCIATES FREDERICK CROSSING LLC

Provider Business Mailing Address
First Line	:	5960 FREDERICK CROSSING LN
Second Line	:
City	:	FREDERICK
State	:	MD
Zip	:	21704-5164
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5960 FREDERICK CROSSING LN
Second Line	:
City	:	FREDERICK
State	:	MD
Zip	:	21704-5164
Country	:	US
Telephone Number	:	301-662-2160
Fax Number	:	301-662-7449

Authorized Official
Title or Position	:	VP INSURANCE PLAN MANAGEMENT
Name	:	MIKE COLE
Credential	:
Telephone Number	:	727-726-1611

Provider Enumeration Date	:	01/07/2014
Last Update Date	:	01/07/2014

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