Healthcare Provider Details

I. General information

NPI: 1083011910
Provider Name (Legal Business Name): GARY P LUDKA D D S P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4373 NORTHVIEW DR
BOWIE MD
20716-2603
US

IV. Provider business mailing address

4373 NORTHVIEW DR
BOWIE MD
20716-2603
US

V. Phone/Fax

Practice location:
  • Phone: 301-464-8707
  • Fax: 301-464-4609
Mailing address:
  • Phone: 301-464-8707
  • Fax: 301-464-4609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9196
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY P LUDKA
Title or Position: DENTIST
Credential: DDS
Phone: 301-464-8707