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General NPI Number Information
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NPI Number | 1457085920
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Entity Type | Individual
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Provider Name | FLAVIO DE MENDONCA COPELLO SR. DDS, PHD
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Gender | Male
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Dates
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Enumeration Date | 07/12/2022
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Last Update Date | 07/12/2022
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Provider Practice Location Address
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Address Line | 650 W BALTIMORE ST STE 3219
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City | BALTIMORE
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State | MD
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Zip | 21201-1510
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Country | US
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Telephone | 410-706-2659
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Fax |
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Provider Business Mailing Address
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Address Line | 414 LIGHT ST UNIT 4002
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City | BALTIMORE
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State | MD
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Zip | 21202-1344
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Country | US
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Telephone | 410-804-3239
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 101
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License Number State | MD
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