Healthcare Provider Details

I. General information

NPI: 1790162998
Provider Name (Legal Business Name): SPECIALIST IN ORTHODONTICS OF MARYLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9812 FALLS ROAD
POTOMAC MD
20854
US

IV. Provider business mailing address

2970 BRANDYWINE RD STE 200
ATLANTA GA
30341
US

V. Phone/Fax

Practice location:
  • Phone: 770-692-1000
  • Fax:
Mailing address:
  • Phone: 770-692-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number14922
License Number StateMD

VIII. Authorized Official

Name: JO ANN RICE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 470-881-8679