=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376820654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S DENTISTRY AT ODENTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2011
-----------------------------------------------------
Last Update Date | 11/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 ANNAPOLIS RD SUITE 106
-----------------------------------------------------
City | ODENTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21113-1344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-672-1100
-----------------------------------------------------
Fax | 410-672-1107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1215 ANNAPOLIS RD SUITE 106
-----------------------------------------------------
City | ODENTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21113-1344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-672-1100
-----------------------------------------------------
Fax | 410-672-1107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARIA SEVILLA GUEVARA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 410-672-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 12374
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------