Healthcare Provider Details

I. General information

NPI: 1942670799
Provider Name (Legal Business Name): ANDREA PELLOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3319 W BELVEDERE AVE
BALTIMORE MD
21215-5143
US

IV. Provider business mailing address

6005 BELLE GROVE RD
BALTIMORE MD
21225-3261
US

V. Phone/Fax

Practice location:
  • Phone: 410-542-7800
  • Fax: 410-542-2039
Mailing address:
  • Phone: 410-919-8278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7148
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: