Healthcare Provider Details

I. General information

NPI: 1295279024
Provider Name (Legal Business Name): PGN DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14420 OLD MILL RD STE 101
UPPER MARLBORO MD
20772-3096
US

IV. Provider business mailing address

14420 OLD MILL RD STE 101
UPPER MARLBORO MD
20772-3096
US

V. Phone/Fax

Practice location:
  • Phone: 301-627-6686
  • Fax:
Mailing address:
  • Phone: 301-627-6686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14871
License Number StateMD

VIII. Authorized Official

Name: DAWN BEREZOSKI
Title or Position: RECEPTION/FINANCIAL
Credential:
Phone: 301-627-6687