Healthcare Provider Details

I. General information

NPI: 1225694029
Provider Name (Legal Business Name): SOUTHERN MARYLAND FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 07/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1438 DEFENSE HWY STE 101
GAMBRILLS MD
21054-2023
US

IV. Provider business mailing address

1438 DEFENSE HWY STE 101
GAMBRILLS MD
21054-2023
US

V. Phone/Fax

Practice location:
  • Phone: 410-721-3567
  • Fax:
Mailing address:
  • Phone: 410-721-3567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHAEL S SAOUD
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 301-848-5321