Healthcare Provider Details

I. General information

NPI: 1386036234
Provider Name (Legal Business Name): DE LA SOLE PODIATRIC MEDICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10507 OBSERVATORY PL
UPPER MARLBORO MD
20772-8511
US

IV. Provider business mailing address

10507 OBSERVATORY PL
UPPER MARLBORO MD
20772-8511
US

V. Phone/Fax

Practice location:
  • Phone: 404-606-7449
  • Fax:
Mailing address:
  • Phone: 404-606-7449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number01544
License Number StateMD

VIII. Authorized Official

Name: DR. KIANA RENE TRENT
Title or Position: OWNER
Credential: DPM
Phone: 404-606-7449