Healthcare Provider Details

I. General information

NPI: 1265341721
Provider Name (Legal Business Name): COLUMBIA MODERN DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8221B GATEWAY OVERLOOK DR
ELKRIDGE MD
21075-6454
US

IV. Provider business mailing address

PO BOX 660041
DALLAS TX
75266-0041
US

V. Phone/Fax

Practice location:
  • Phone: 443-730-4100
  • Fax: 443-737-4001
Mailing address:
  • Phone: 714-845-8890
  • Fax: 303-952-0892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KIRSTIE A NINAN
Title or Position: OWNER
Credential: DDS
Phone: 443-730-4100