=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023450681
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYCOVE FAMILY AND COSMETIC DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2013
-----------------------------------------------------
Last Update Date | 07/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 780 RITCHIE HWY SUITE S 30
-----------------------------------------------------
City | SEVERNA PARK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21146-4135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-384-9030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 780 RITCHIE HWY SUITE S 30
-----------------------------------------------------
City | SEVERNA PARK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21146-4135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-384-9030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH Z BENDERSON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 410-384-9030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 13157
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------