Healthcare Provider Details

I. General information

NPI: 1982872644
Provider Name (Legal Business Name): BETHESDA TMJ FACIAL PAIN TREATMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10215 FERNWOOD RD #601
BETHESDA MD
20817
US

IV. Provider business mailing address

10215 FERNWOOD ROAD #601
BETHESDA MD
20817
US

V. Phone/Fax

Practice location:
  • Phone: 301-897-3350
  • Fax:
Mailing address:
  • Phone: 301-897-3350
  • Fax: 301-897-5571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number7317
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number12705
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number4590
License Number StateMD

VIII. Authorized Official

Name: FAITH K ANDERSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 301-897-3350