Healthcare Provider Details

I. General information

NPI: 1548661614
Provider Name (Legal Business Name): IB DENTAL II, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

30A AUDREY LANE
OXON HILL MD
20745-1301
US

IV. Provider business mailing address

30A AUDREY LANE
OXON HILL MD
20745-1301
US

V. Phone/Fax

Practice location:
  • Phone: 301-567-5437
  • Fax: 301-567-5456
Mailing address:
  • Phone: 301-567-5437
  • Fax: 301-567-5456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14139
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number14139
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number14139
License Number StateMD

VIII. Authorized Official

Name: DR. ROBERT DAYSE
Title or Position: OWNER/DIRECTOR
Credential: DDS, MBA
Phone: 301-567-5437