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General NPI Number Information
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NPI Number | 1437550761
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Entity Type | Organization
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Legal Business Name | EASTERN AVENUE DENTAL, LLC
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Dates
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Enumeration Date | 09/05/2014
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Last Update Date | 09/09/2014
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Provider Practice Location Address
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Address Line | 12412 EASTERN AVE
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City | BALTIMORE
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State | MD
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Zip | 21220
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Country | US
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Telephone | 410-335-7771
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX B
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City | CHASE
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State | MD
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Zip | 21027-0020
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Country | US
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Telephone | 410-335-7771
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | SINHA KANG
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Credential |
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Telephone | 410-335-7771
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12853
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 14921
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License Number State | MD
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 15012
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License Number State | MD
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Taxonomy #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 13144
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License Number State | MD
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