Healthcare Provider Details

I. General information

NPI: 1891552196
Provider Name (Legal Business Name): PARK AND SCORNAVACA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9727 GREENSIDE DR STE 102
COCKEYSVILLE MD
21030-5000
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: 302-836-5072
  • Fax: 302-836-2690

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: MR. JOHN T MOORE
Title or Position: GENERAL MANAGER
Credential:
Phone: 302-562-0060