Healthcare Provider Details

I. General information

NPI: 1043863186
Provider Name (Legal Business Name): SPECIALISTS IN ORTHODONTICS OF MARYLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13600 BALTIMORE AVE STE 200
LAUREL MD
20707-9495
US

IV. Provider business mailing address

2970 BRANDYWINE RD STE 200
ATLANTA GA
30341-5549
US

V. Phone/Fax

Practice location:
  • Phone: 301-470-2137
  • Fax:
Mailing address:
  • Phone: 770-692-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JO ANN RICE
Title or Position: CREDENTIALING DIRECTOR
Credential:
Phone: 609-315-3851