Healthcare Provider Details

I. General information

NPI: 1912221649
Provider Name (Legal Business Name): DRKBCHASELLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2010
Last Update Date: 03/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23808 HOLLYWOOD RD
LEONARDTOWN MD
20650-5825
US

IV. Provider business mailing address

23808 HOLLYWOOD RD
LEONARDTOWN MD
20650-5825
US

V. Phone/Fax

Practice location:
  • Phone: 301-475-5926
  • Fax: 301-475-2653
Mailing address:
  • Phone: 301-475-5926
  • Fax: 301-475-2653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6787
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number14062
License Number StateMD

VIII. Authorized Official

Name: DR. KENNETH BERNARD CHASE
Title or Position: OWNER
Credential: D.D.S.
Phone: 301-475-5926