=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417350281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD NEIGHBOR DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2014
-----------------------------------------------------
Last Update Date | 10/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12051 CHESTNUT BRANCH WAY STE C3
-----------------------------------------------------
City | CLARKSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20871-5328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-355-4789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12051 CHESTNUT BRANCH WAY STE C3
-----------------------------------------------------
City | CLARKSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20871-5328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-355-4789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | KYU J LEE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 301-355-4789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 15618
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------