MEDICARE: PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT

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	1223D0001X	Public Health Dentistry

General Provider Information

NPI Number	:	1518003565
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT

Provider Business Mailing Address
First Line	:	1701 MCCORMICK DR
Second Line	:	SUITE 120
City	:	LARGO
State	:	MD
Zip	:	20774-5329
Country	:	US
Telephone Number	:	301-883-7861
Fax Number	:

Provider Business Practice Location Address
First Line	:	3003 HOSPITAL DR
Second Line	:
City	:	CHEVERLY
State	:	MD
Zip	:	20785-1194
Country	:	US
Telephone Number	:	301-583-5900
Fax Number	:

Authorized Official
Title or Position	:	MANAGER, CLIENT INFORMATION SERVICE
Name	:	MRS. DARLENE WHITAKER
Credential	:
Telephone Number	:	301-883-7861

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	06/23/2009

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