Healthcare Provider Details

I. General information

NPI: 1144324773
Provider Name (Legal Business Name): BALTIMORE AVE. DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7305 BALTIMORE AVE SUITE 205
COLLEGE PARK MD
20740-3234
US

IV. Provider business mailing address

7305 BALTIMORE AVE SUITE 205
COLLEGE PARK MD
20740-3234
US

V. Phone/Fax

Practice location:
  • Phone: 301-927-2500
  • Fax: 301-927-2555
Mailing address:
  • Phone: 301-927-2500
  • Fax: 301-927-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3300
License Number StateMD

VIII. Authorized Official

Name: STANLEY BRAGER
Title or Position: DENTIST
Credential: DDS
Phone: 301-927-2500