Healthcare Provider Details

I. General information

NPI: 1902072408
Provider Name (Legal Business Name): CHA-CAMP DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20036 GOSHEN RD
GAITHERSBURG MD
20879-1604
US

IV. Provider business mailing address

20036 GOSHEN RD
GAITHERSBURG MD
20879-1604
US

V. Phone/Fax

Practice location:
  • Phone: 240-683-6009
  • Fax:
Mailing address:
  • Phone: 240-683-6009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number13607
License Number StateMD

VIII. Authorized Official

Name: DR. CHARMAINE THERESA CHA-CAMP
Title or Position: DENTIST
Credential: D.D.S.
Phone: 301-537-6192