Healthcare Provider Details

I. General information

NPI: 1083363410
Provider Name (Legal Business Name): CCDC PROFESSIONALS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 BENSON AVE STE G100
BALTIMORE MD
21227-1134
US

IV. Provider business mailing address

1220 CARAWAY CT STE 1050
UPPER MARLBORO MD
20774-5338
US

V. Phone/Fax

Practice location:
  • Phone: 301-494-3000
  • Fax:
Mailing address:
  • Phone: 301-494-3000
  • Fax: 301-494-3333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY WHEELER
Title or Position: BUSINESS MANAGER
Credential:
Phone: 301-494-3000