Healthcare Provider Details

I. General information

NPI: 1932516804
Provider Name (Legal Business Name): SANJU P. JOSE D.D.S., M.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2014
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6395 DOBBIN RD STE 208
COLUMBIA MD
21045-4759
US

IV. Provider business mailing address

300 PINE VALLEY DR
IMPERIAL PA
15126-9332
US

V. Phone/Fax

Practice location:
  • Phone: 410-997-1189
  • Fax: 410-992-5474
Mailing address:
  • Phone: 410-913-4760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number16308
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: