=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306642848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMALLTOWNE DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2025
-----------------------------------------------------
Last Update Date | 03/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6620 CRAIN HWY STE 204
-----------------------------------------------------
City | LA PLATA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20646-4273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-870-3966
-----------------------------------------------------
Fax | 301-753-1992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6620 CRAIN HWY STE 204
-----------------------------------------------------
City | LA PLATA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20646-4273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-870-3966
-----------------------------------------------------
Fax | 301-753-1992
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DEMION CORNWALL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 646-436-2195
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------