Healthcare Provider Details

I. General information

NPI: 1184492068
Provider Name (Legal Business Name): OPNE WIDE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2023
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 S FULTON AVE
BALTIMORE MD
21223-3004
US

IV. Provider business mailing address

221 S FULTON AVE
BALTIMORE MD
21223-3004
US

V. Phone/Fax

Practice location:
  • Phone: 410-258-0189
  • Fax:
Mailing address:
  • Phone: 410-258-0189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126900000X
TaxonomyDental Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name: TERRANCE SHATEEK LAWRENCE
Title or Position: DENTAL LAB TECHNICIAN
Credential:
Phone: 410-258-0189