=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154253672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN MARYLAND ORTHODONTIC STUDIO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2026
-----------------------------------------------------
Last Update Date | 06/01/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5020 BROWN STATION RD STE 130
-----------------------------------------------------
City | UPPER MARLBORO
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20772-9107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-327-1223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 V ST NW APT 301
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20001-5779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. BRANDON HAGAN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 502-821-7651
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------