Healthcare Provider Details

I. General information

NPI: 1477897858
Provider Name (Legal Business Name): FAMILY DENTAL WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2012
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 MEADOWRIDGE CENTER DR
ELKRIDGE MD
21075-6088
US

IV. Provider business mailing address

6020 MEADOWRIDGE CENTER DR
ELKRIDGE MD
21075-6088
US

V. Phone/Fax

Practice location:
  • Phone: 410-782-3124
  • Fax:
Mailing address:
  • Phone: 410-782-3124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13217
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMIA AZHAR
Title or Position: DENTIST
Credential: DDS
Phone: 443-857-5317