=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174637185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONGMEADOW FAMILY DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 11/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19638 LEITERSBURG PIKE SUITE 103
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-739-1100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19638 LEITERSBURG PIKE SUITE 103
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21742-1438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-739-1100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES/OWNER
-----------------------------------------------------
Name | DR. BRANDON KEITH ELLIS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 301-739-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 14739
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12508
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------