Healthcare Provider Details

I. General information

NPI: 1609412592
Provider Name (Legal Business Name): NUCLEAR SMILES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10100 TWIN RIVERS RD APT 121
COLUMBIA MD
21044-2578
US

IV. Provider business mailing address

2104 DIXON RD
FREDERICK MD
21704-8135
US

V. Phone/Fax

Practice location:
  • Phone: 301-538-0719
  • Fax:
Mailing address:
  • Phone: 301-538-0719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JON A MOLES
Title or Position: OWNER
Credential: DDS
Phone: 301-538-0719