Healthcare Provider Details

I. General information

NPI: 1336902097
Provider Name (Legal Business Name): CARROLL COUNTY PEDIATRIC DENTISTRY & ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 02/05/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 WASHINGTON HEIGHTS MEDICAL CENTER
WESTMINSTER MD
21157
US

IV. Provider business mailing address

1302 MUSGROVE ROAD
TIMONIUM MD
21093
US

V. Phone/Fax

Practice location:
  • Phone: 443-487-9435
  • Fax:
Mailing address:
  • Phone: 410-935-8016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MARSHALL WESLEY FESCHE
Title or Position: OWNER
Credential: D.D.S.
Phone: 410-935-8016