Healthcare Provider Details

I. General information

NPI: 1417298472
Provider Name (Legal Business Name): R3 DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14301 LAYHILL RD STE 102
SILVER SPRING MD
20906-1937
US

IV. Provider business mailing address

14301 LAYHILL RD STE 102
SILVER SPRING MD
20906-1937
US

V. Phone/Fax

Practice location:
  • Phone: 301-438-1200
  • Fax:
Mailing address:
  • Phone: 301-438-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13854
License Number StateMD

VIII. Authorized Official

Name: DR. ALIREZA OMID RAJAEI
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 617-599-0599