Healthcare Provider Details

I. General information

NPI: 1104226653
Provider Name (Legal Business Name): SKP FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7525 GREENWAY CENTER DR STE 310
GREENBELT MD
20770-3525
US

IV. Provider business mailing address

7525 GREENWAY CENTER DR STE 310
GREENBELT MD
20770-3525
US

V. Phone/Fax

Practice location:
  • Phone: 240-553-7772
  • Fax: 240-553-7782
Mailing address:
  • Phone: 240-553-7772
  • Fax: 240-553-7782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number15553
License Number StateMD

VIII. Authorized Official

Name: DR. PAULOS F DALU
Title or Position: DENTIST
Credential:
Phone: 240-553-7772