Healthcare Provider Details

I. General information

NPI: 1558667980
Provider Name (Legal Business Name): STEVEN ROBERT KISHTER M.D., D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 08/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11404 OLD GEORGETOWN RD SUITE 104
ROCKVILLE MD
20852-2865
US

IV. Provider business mailing address

11404 OLD GEORGETOWN RD SUITE 104
ROCKVILLE MD
20852-2865
US

V. Phone/Fax

Practice location:
  • Phone: 301-984-9111
  • Fax: 301-984-0374
Mailing address:
  • Phone: 301-984-9111
  • Fax: 301-984-0374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8776
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD0041703
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: