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General NPI Number Information
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NPI Number | 1164005419
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Entity Type | Organization
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Legal Business Name | BETHESDA ORTHODONTIC SPECIALIST
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Dates
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Enumeration Date | 05/04/2021
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Last Update Date | 06/15/2021
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Provider Practice Location Address
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Address Line | 4405 E WEST HWY STE 102
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City | BETHESDA
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State | MD
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Zip | 20814-4532
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Country | US
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Telephone | 301-654-3011
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Fax |
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Provider Business Mailing Address
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Address Line | 4405 E WEST HWY STE 102
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City | BETHESDA
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State | MD
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Zip | 20814-4532
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Country | US
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Telephone | 301-654-3011
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JONATHAN LY
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Credential |
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Telephone | 301-654-3011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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