Healthcare Provider Details

I. General information

NPI: 1154253672
Provider Name (Legal Business Name): SOUTHERN MARYLAND ORTHODONTIC STUDIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 BROWN STATION RD STE 130
UPPER MARLBORO MD
20772-9107
US

IV. Provider business mailing address

205 V ST NW APT 301
WASHINGTON DC
20001-5779
US

V. Phone/Fax

Practice location:
  • Phone: 301-327-1223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. BRANDON HAGAN
Title or Position: ORTHODONTIST
Credential: DMD
Phone: 502-821-7651