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General NPI Number Information
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NPI Number | 1194964015
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Entity Type | Organization
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Legal Business Name | NORTHWEST DENTAL INC
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Dates
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Enumeration Date | 02/17/2009
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Last Update Date | 02/17/2009
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Provider Practice Location Address
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Address Line | 4821 BUTLER ROAD SUITE 2B
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City | GLYNDON
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State | MD
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Zip | 21071
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Country | US
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Telephone | 410-486-5580
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Fax | 410-484-6365
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Provider Business Mailing Address
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Address Line | 4821 BUTLER ROAD SUITE 2B
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City | GLYNDON
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State | MD
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Zip | 21071
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Country | US
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Telephone | 410-486-5580
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Fax | 410-484-6365
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Authorized Official
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Title or Position | DENTIST
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Name | DR. PHILLIP B SUROSKY
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Credential | D.D.S.
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Telephone | 410-486-5580
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 7474
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License Number State | MD
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