Healthcare Provider Details

I. General information

NPI: 1255600334
Provider Name (Legal Business Name): UNIVERSITY OF MARYLAND DENTAL SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2011
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W BALTIMORE ST
BALTIMORE MD
21201-1510
US

IV. Provider business mailing address

650 W BALTIMORE ST
BALTIMORE MD
21201-1510
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-7542
  • Fax:
Mailing address:
  • Phone: 410-706-7542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number7967
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number07967
License Number StateMD

VIII. Authorized Official

Name: DR. GARY D. HACK
Title or Position: ASSOCIATE PROFESSOR
Credential: DDS
Phone: 410-707-7047