MEDICARE: MARYLAND DENTAL ASSOCIATES 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

General Provider Information

NPI Number	:	1720725351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARYLAND DENTAL ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	3450 OLD WASHINGTON RD STE 301
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20602-3251
Country	:	US
Telephone Number	:	301-645-6611
Fax Number	:

Provider Business Practice Location Address
First Line	:	3450 OLD WASHINGTON RD STE 301
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20602-3251
Country	:	US
Telephone Number	:	301-645-6611
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	R PATRICIA HOWER
Credential	:
Telephone Number	:	215-798-4027

Provider Enumeration Date	:	05/16/2022
Last Update Date	:	05/20/2022

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