=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114084514
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAUREL PINES DENTAL GROUP, CHARTERED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2007
-----------------------------------------------------
Last Update Date | 11/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14333 LAUREL BOWIE RD SUITE 100
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20708-1126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-953-3081
-----------------------------------------------------
Fax | 301-725-4885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14333 LAUREL BOWIE RD SUITE 100
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20708-1126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-953-3081
-----------------------------------------------------
Fax | 301-725-4885
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. THOMAS A'BECKET
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 301-953-3081
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------