Healthcare Provider Details

I. General information

NPI: 1215768254
Provider Name (Legal Business Name): KEYSTONE ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9727 GREENSIDE DR
COCKEYSVILLE MD
21030-5030
US

IV. Provider business mailing address

1250 PEOPLES PLZ
NEWARK DE
19702-5701
US

V. Phone/Fax

Practice location:
  • Phone: 410-667-6404
  • Fax:
Mailing address:
  • Phone: 302-299-5617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ROBERT PARK
Title or Position: OWNER
Credential: DMD
Phone: 302-299-5617