Healthcare Provider Details

I. General information

NPI: 1881054641
Provider Name (Legal Business Name): STOREHOUSE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 POINTER RIDGE PL SUITE A
BOWIE MD
20716-1881
US

IV. Provider business mailing address

1540 POINTER RIDGE PL SUITE A
BOWIE MD
20716-1881
US

V. Phone/Fax

Practice location:
  • Phone: 301-218-2454
  • Fax: 301-218-2455
Mailing address:
  • Phone: 301-218-2454
  • Fax: 301-218-2455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number14231
License Number StateMD

VIII. Authorized Official

Name: DR. STAFFORD GARFIELD CONLEY JR.
Title or Position: OWNER
Credential: DDS
Phone: 301-218-2454