Healthcare Provider Details

I. General information

NPI: 1407246168
Provider Name (Legal Business Name): KEROLOS MICHAEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 05/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12520 PROSPERITY DR STE 340
SILVER SPRING MD
20904-1606
US

IV. Provider business mailing address

12520 PROSPERITY DR STE 340
SILVER SPRING MD
20904-1606
US

V. Phone/Fax

Practice location:
  • Phone: 301-388-2420
  • Fax:
Mailing address:
  • Phone: 301-388-2420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS040257
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number16379
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: