Healthcare Provider Details

I. General information

NPI: 1205242187
Provider Name (Legal Business Name): RUTH OWUSU-BOAHENE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2014
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 OLD COLUMBIA RD STE H
COLUMBIA MD
21046-2275
US

IV. Provider business mailing address

10000 OLD COLUMBIA RD STE H
COLUMBIA MD
21046-2275
US

V. Phone/Fax

Practice location:
  • Phone: 443-542-9519
  • Fax: 443-288-4402
Mailing address:
  • Phone: 443-542-9519
  • Fax: 443-288-4402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number15603
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: