=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245455401
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY P LUDKA D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4373 NORTHVIEW DR
-----------------------------------------------------
City | BOWIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20716-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-464-8707
-----------------------------------------------------
Fax | 301-464-4609
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1609 EDGERTON PL
-----------------------------------------------------
City | CROFTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21114-1504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-721-5849
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9196
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------