Healthcare Provider Details

I. General information

NPI: 1902855422
Provider Name (Legal Business Name): MARYLAND DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15204 OMEGA DR SUITE 140
ROCKVILLE MD
20850-4601
US

IV. Provider business mailing address

15204 OMEGA DR SUITE 140
ROCKVILLE MD
20850-4601
US

V. Phone/Fax

Practice location:
  • Phone: 301-869-7733
  • Fax:
Mailing address:
  • Phone: 301-869-7733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12369
License Number StateMD

VIII. Authorized Official

Name: DR. SHOBA A DANEY
Title or Position: DENTIST
Credential: DMD
Phone: 301-869-7733