Healthcare Provider Details

I. General information

NPI: 1508399080
Provider Name (Legal Business Name): TIMONIUM DENTAL & SPECIALTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2135 YORK RD STE A
TIMONIUM MD
21093-3137
US

IV. Provider business mailing address

46 VREELAND DR STE 6
SKILLMAN NJ
08558-2638
US

V. Phone/Fax

Practice location:
  • Phone: 410-910-9641
  • Fax:
Mailing address:
  • Phone: 609-252-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: BRYAN FITZGERALD
Title or Position: OWNER
Credential: DDS
Phone: 410-910-9641