MEDICARE: ST. CHARLES FAMILY DENTAL

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1619359213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. CHARLES FAMILY DENTAL

Provider Business Mailing Address
First Line	:	173 SAINT PATRICKS DR
Second Line	:	SUITE 204
City	:	WALDORF
State	:	MD
Zip	:	20603-5529
Country	:	US
Telephone Number	:	301-645-6500
Fax Number	:	301-632-6492

Provider Business Practice Location Address
First Line	:	173 SAINT PATRICKS DR
Second Line	:	SUITE 204
City	:	WALDORF
State	:	MD
Zip	:	20603-5529
Country	:	US
Telephone Number	:	301-645-6500
Fax Number	:	301-632-6492

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. MARILYN COLEMAN-BORDES
Credential	:	OWNER
Telephone Number	:	301-645-6500

Provider Enumeration Date	:	06/19/2015
Last Update Date	:	06/19/2015

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