=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043694623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREDERICK KIDDS PEDIATRIC DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2015
-----------------------------------------------------
Last Update Date | 07/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 SHOREBIRD ST STE B
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21701-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-202-5041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 SHOREBIRD ST STE B
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21701-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-202-5041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | D'AUDRA COLE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 301-202-5041
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 14079
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------