Healthcare Provider Details

I. General information

NPI: 1912564626
Provider Name (Legal Business Name): KENTLANDS PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 KENT SQUARE RD
GAITHERSBURG MD
20878-5650
US

IV. Provider business mailing address

108 KENT SQUARE RD
GAITHERSBURG MD
20878-5650
US

V. Phone/Fax

Practice location:
  • Phone: 240-888-3609
  • Fax:
Mailing address:
  • Phone: 240-888-3609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ELLIE SEPEHRI
Title or Position: PHYSICIAN
Credential: MD
Phone: 240-888-3609