MEDICARE: SOUTHERN MARYLAND ORTHODONTIC STUDIO 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1154253672
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN MARYLAND ORTHODONTIC STUDIO LLC

Provider Business Mailing Address
First Line	:	205 V ST NW APT 301
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20001-5779
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5020 BROWN STATION RD STE 130
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-9107
Country	:	US
Telephone Number	:	301-327-1223
Fax Number	:

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. BRANDON HAGAN
Credential	:	DMD
Telephone Number	:	502-821-7651

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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