Healthcare Provider Details

I. General information

NPI: 1649641663
Provider Name (Legal Business Name): PEDIATRIC DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

11904 DARNESTOWN RD STE D
NORTH POTOMAC MD
20878-3202
US

IV. Provider business mailing address

11904 DARNESTOWN RD STE D
NORTH POTOMAC MD
20878-3202
US

V. Phone/Fax

Practice location:
  • Phone: 240-683-8040
  • Fax:
Mailing address:
  • Phone: 240-683-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number11552
License Number StateMD

VIII. Authorized Official

Name: FARIBA PARYAVI
Title or Position: PEDIATRIC DENTIST
Credential:
Phone: 240-683-8040