Healthcare Provider Details

I. General information

NPI: 1417334079
Provider Name (Legal Business Name): ENDODONTIC SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12520 PROSPERITY DR STE 230
SILVER SPRING MD
20904-1683
US

IV. Provider business mailing address

12520 PROSPERITY DR STE 230
SILVER SPRING MD
20904-1683
US

V. Phone/Fax

Practice location:
  • Phone: 301-593-4400
  • Fax: 301-593-1587
Mailing address:
  • Phone: 301-593-4400
  • Fax: 301-593-1587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: YOUNG S LEE
Title or Position: PRESIDENT
Credential: DMD
Phone: 301-593-4400