Healthcare Provider Details

I. General information

NPI: 1356644512
Provider Name (Legal Business Name): GREENWAY DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2010
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7525 GREENWAY CENTER DR 102
GREENBELT MD
20770-3509
US

IV. Provider business mailing address

7525 GREENWAY CENTER DR 102
GREENBELT MD
20770-3509
US

V. Phone/Fax

Practice location:
  • Phone: 301-345-2880
  • Fax: 301-345-6287
Mailing address:
  • Phone: 301-345-2880
  • Fax: 301-345-6287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13883
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number6317
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12653
License Number StateMD

VIII. Authorized Official

Name: KATIE ALSOP
Title or Position: FINANCIAL MANAGER
Credential:
Phone: 301-345-2880