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General NPI Number Information
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NPI Number | 1407474380
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Entity Type | Organization
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Legal Business Name | RUSSELL PARK DENTAL CARE, LLC
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Dates
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Enumeration Date | 07/08/2020
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Last Update Date | 07/08/2020
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Provider Practice Location Address
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Address Line | 963 RUSSELL AVE STE A
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City | GAITHERSBURG
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State | MD
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Zip | 20879-3287
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Country | US
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Telephone | 301-284-8467
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Fax |
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Provider Business Mailing Address
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Address Line | 963 RUSSELL AVE STE A
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City | GAITHERSBURG
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State | MD
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Zip | 20879-3287
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Country | US
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Telephone | 301-284-8467
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. VIGEN SIMCHIAN
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Credential | DDS
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Telephone | 301-284-8467
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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 |
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License Number State |
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