Healthcare Provider Details

I. General information

NPI: 1619504362
Provider Name (Legal Business Name): MRS. TATYANA PENN BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N CHARLES ST
BALTIMORE MD
21201-5505
US

IV. Provider business mailing address

18 PINE CHIP CT
NOTTINGHAM MD
21236-3542
US

V. Phone/Fax

Practice location:
  • Phone: 410-837-2050
  • Fax:
Mailing address:
  • Phone: 301-356-7960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17587
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: