Healthcare Provider Details

I. General information

NPI: 1831489988
Provider Name (Legal Business Name): DENTAL ONE ASSOCIATES SECURITY BLVD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6666 SECURITY BLVD
BALTIMORE MD
21207-4013
US

IV. Provider business mailing address

6666 SECURITY BLVD
BALTIMORE MD
21207-4013
US

V. Phone/Fax

Practice location:
  • Phone: 410-944-6666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MIKE COLE
Title or Position: INSURANCE DIRECTOR
Credential:
Phone: 727-726-1611