Healthcare Provider Details

I. General information

NPI: 1861077208
Provider Name (Legal Business Name): TINY TOOTH PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8808 CENTRE PARK DR STE 303
COLUMBIA MD
21045-2224
US

IV. Provider business mailing address

8032 TROTTERS CHASE
ELLICOTT CITY MD
21043-7592
US

V. Phone/Fax

Practice location:
  • Phone: 443-812-8027
  • Fax:
Mailing address:
  • Phone: 443-812-8027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SU KIM
Title or Position: PEDIATRIC DENTIST
Credential: DDS
Phone: 443-812-8027