Healthcare Provider Details

I. General information

NPI: 1184116618
Provider Name (Legal Business Name): KIDDIE CAVITY CARE THMD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3743 BRANCH AVE STE A
TEMPLE HILLS MD
20748-1408
US

IV. Provider business mailing address

8605 KITTAMA DR
CLINTON MD
20735-3179
US

V. Phone/Fax

Practice location:
  • Phone: 240-606-2699
  • Fax:
Mailing address:
  • Phone: 240-606-2699
  • 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 Code1223P0221X
TaxonomyPediatric Dentistry
License Number16208
License Number StateMD

VIII. Authorized Official

Name: DR. EPHRAIM L ALTMON
Title or Position: OWNER
Credential: DDS
Phone: 240-606-2699