Healthcare Provider Details

I. General information

NPI: 1144715533
Provider Name (Legal Business Name): MARK LIMSAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4195 MOUNTAIN RD
PASADENA MD
21122-4455
US

IV. Provider business mailing address

4195 MOUNTAIN RD
PASADENA MD
21122-4455
US

V. Phone/Fax

Practice location:
  • Phone: 410-255-8001
  • Fax: 410-255-0687
Mailing address:
  • Phone: 410-255-8001
  • Fax: 410-255-0687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11438
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17317
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: