Healthcare Provider Details

I. General information

NPI: 1942548540
Provider Name (Legal Business Name): KIDS SUPER SMILE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 SNOWDEN RIVER PKWY 302
COLUMBIA MD
21045-1982
US

IV. Provider business mailing address

8600 SNOWDEN RIVER PKWY 302
COLUMBIA MD
21045-1982
US

V. Phone/Fax

Practice location:
  • Phone: 410-953-0111
  • Fax: 410-953-0193
Mailing address:
  • Phone: 410-953-0111
  • Fax: 410-953-0193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12833
License Number StateMD

VIII. Authorized Official

Name: DR. XIMENA PAREJA
Title or Position: OFFICER
Credential: DDS
Phone: 410-953-0111