Healthcare Provider Details

I. General information

NPI: 1386009405
Provider Name (Legal Business Name): LUSBY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10025 HG TRUEMAN ROAD
LUSBY MD
20657
US

IV. Provider business mailing address

10025 HG TRUEMAN RD
LUSBY MD
20657-2868
US

V. Phone/Fax

Practice location:
  • Phone: 301-862-3900
  • Fax:
Mailing address:
  • Phone: 410-326-4078
  • Fax: 410-326-9311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID JACK COOPER
Title or Position: OWNER
Credential: DDS
Phone: 410-326-4078