MEDICARE: BURTONSVILLE DENTAL GROUP 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	12906	MD

General Provider Information

NPI Number	:	1992129928
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BURTONSVILLE DENTAL GROUP LLC

Provider Business Mailing Address
First Line	:	3905 NATIONAL DR
Second Line	:	#260
City	:	BURTONSVILLE
State	:	MD
Zip	:	20866-1100
Country	:	US
Telephone Number	:	301-421-1996
Fax Number	:

Provider Business Practice Location Address
First Line	:	3905 NATIONAL DR
Second Line	:	#260
City	:	BURTONSVILLE
State	:	MD
Zip	:	20866-1100
Country	:	US
Telephone Number	:	301-421-1996
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	GARY ADAMS
Credential	:
Telephone Number	:	301-421-1996

Provider Enumeration Date	:	02/11/2014
Last Update Date	:	02/11/2014

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