Healthcare Provider Details

I. General information

NPI: 1508829458
Provider Name (Legal Business Name): DOUGLAS LA ROI RISK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 08/29/2023
Certification Date: 08/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13350 HG TRUMAN
SOLOMONS MD
20688
US

IV. Provider business mailing address

3715 CHANCELLORS RUN PL
NANJEMOY MD
20662-3033
US

V. Phone/Fax

Practice location:
  • Phone: 410-326-4078
  • Fax:
Mailing address:
  • Phone: 240-682-1019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number16615
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN4845
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16615
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: