Healthcare Provider Details

I. General information

NPI: 1447352521
Provider Name (Legal Business Name): DANTE S LLACUNA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12505 HAXALL CT
FORT WASHINGTON MD
20744-7042
US

IV. Provider business mailing address

12505 HAXALL CT
FORT WASHINGTON MD
20744-7042
US

V. Phone/Fax

Practice location:
  • Phone: 301-292-6877
  • Fax:
Mailing address:
  • Phone: 301-292-6877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD0017711
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: