Healthcare Provider Details

I. General information

NPI: 1992476469
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 09/24/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10085 DUNKIRK WAY STE 103
DUNKIRK MD
20754-2024
US

IV. Provider business mailing address

PO BOX 219
DUNKIRK MD
20754-0219
US

V. Phone/Fax

Practice location:
  • Phone: 410-257-7676
  • Fax: 410-257-7676
Mailing address:
  • Phone: 410-257-7676
  • Fax: 410-257-5212

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. JOSE CARLOS JUAMBELTZ
Title or Position: OWNER
Credential: DDS
Phone: 410-257-7676