Healthcare Provider Details

I. General information

NPI: 1629707492
Provider Name (Legal Business Name): MONTGOMERY PEDIATRIC DENTAL PARTNERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14955 SHADY GROVE RD STE 260
ROCKVILLE MD
20850-8723
US

IV. Provider business mailing address

14955 SHADY GROVE RD STE 260
ROCKVILLE MD
20850-8723
US

V. Phone/Fax

Practice location:
  • Phone: 240-752-8822
  • Fax: 240-752-8821
Mailing address:
  • Phone: 240-752-8822
  • Fax: 240-752-8821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: REZA BEHESHTI
Title or Position: CO-OWNER
Credential: DDS
Phone: 240-752-8822