Healthcare Provider Details

I. General information

NPI: 1750491478
Provider Name (Legal Business Name): DAVID SCOTT LAVINE D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12113 DARNESTOWN RD
GAITHERSBURG MD
20878-2205
US

IV. Provider business mailing address

12113 DARNESTOWN RD
GAITHERSBURG MD
20878-2205
US

V. Phone/Fax

Practice location:
  • Phone: 301-977-8717
  • Fax: 301-977-3472
Mailing address:
  • Phone: 301-977-8717
  • Fax: 301-977-3472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11153
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: