Healthcare Provider Details

I. General information

NPI: 1184712309
Provider Name (Legal Business Name): OLWYN DIAMOND D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 SMITH AVE SUITE B
BALTIMORE MD
21209-1453
US

IV. Provider business mailing address

6666 SECURITY BLVD
BALTIMORE MD
21207-4013
US

V. Phone/Fax

Practice location:
  • Phone: 410-486-3636
  • Fax: 410-486-3657
Mailing address:
  • Phone: 410-944-6666
  • Fax: 410-944-1046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7870
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: