Healthcare Provider Details

I. General information

NPI: 1750893095
Provider Name (Legal Business Name): EZ SMILE DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5006 SINCLAIR LN
BALTIMORE MD
21206-5936
US

IV. Provider business mailing address

5006 SINCLAIR LN
BALTIMORE MD
21206-5936
US

V. Phone/Fax

Practice location:
  • Phone: 410-488-0600
  • Fax:
Mailing address:
  • Phone: 410-488-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14008
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number14008
License Number StateMD

VIII. Authorized Official

Name: DR. PAYAM NOURMAND
Title or Position: OWNER
Credential:
Phone: 410-488-0600