Healthcare Provider Details

I. General information

NPI: 1073812913
Provider Name (Legal Business Name): FAMILY COSMETIC & IMPLANT DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3222 POWDER MILL RD
ADELPHI MD
20783-1037
US

IV. Provider business mailing address

3222 POWDER MILL RD
ADELPHI MD
20783-1037
US

V. Phone/Fax

Practice location:
  • Phone: 301-937-8872
  • Fax:
Mailing address:
  • Phone: 301-937-8872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberMD11535
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberMD11549
License Number StateMD

VIII. Authorized Official

Name: DR. MARVALEE M MATTRASINGH
Title or Position: PRESIDENT
Credential: DDS
Phone: 301-937-8872