Healthcare Provider Details

I. General information

NPI: 1841209053
Provider Name (Legal Business Name): JOHN L KRUMPOTICH DDS FAGD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 THOMAS JOHNSON DRIVE SUITE 130
FREDERICK MD
21702
US

IV. Provider business mailing address

196 THOMAS JOHNSON DRIVE SUITE 130
FREDERICK MD
21702
US

V. Phone/Fax

Practice location:
  • Phone: 301-663-5552
  • Fax: 301-663-4629
Mailing address:
  • Phone: 301-663-5552
  • Fax: 301-663-4629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8036
License Number StateMD

VIII. Authorized Official

Name: DR. JOHN LEWIS KRUMPOTICH JR.
Title or Position: DENTIST PRESIDENT
Credential: DDS
Phone: 301-663-5552