Healthcare Provider Details

I. General information

NPI: 1295599686
Provider Name (Legal Business Name): CPDG-CANTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3904 BOSTON ST STE 104
BALTIMORE MD
21224-5762
US

IV. Provider business mailing address

3400 BOX HLL CORP CTR DR STE 120
ABINGDON MD
21009-1290
US

V. Phone/Fax

Practice location:
  • Phone: 410-569-4300
  • Fax:
Mailing address:
  • Phone: 410-569-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. HAKAN KOYMEN
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 410-979-4483