Healthcare Provider Details

I. General information

NPI: 1659703353
Provider Name (Legal Business Name): WOODSBORO DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 S 2ND ST
WOODSBORO MD
21798-8511
US

IV. Provider business mailing address

309 S 2ND ST
WOODSBORO MD
21798-8511
US

V. Phone/Fax

Practice location:
  • Phone: 301-898-7151
  • Fax:
Mailing address:
  • Phone: 301-898-7151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13379
License Number StateMD

VIII. Authorized Official

Name: AMARIS LITTLE RAJASKI
Title or Position: OWNER
Credential: D.D.S.
Phone: 443-756-8875