Healthcare Provider Details

I. General information

NPI: 1457413734
Provider Name (Legal Business Name): ANDREW THEEMAN FRIED DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9712 BELAIR RD STE 304
BALTIMORE MD
21236-1113
US

IV. Provider business mailing address

11410 MARBROOK RD
OWINGS MILLS MD
21117-2342
US

V. Phone/Fax

Practice location:
  • Phone: 410-256-6760
  • Fax: 410-256-4484
Mailing address:
  • Phone: 410-581-5334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number13443
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: