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General NPI Number Information
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NPI Number | 1508802414
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Entity Type | Organization
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Legal Business Name | SHADY GROVE MODERN DENTAL PC
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Dates
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Enumeration Date | 06/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 9051 SHADY GROVE COURT
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City | GAITHERSBURG
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State | MD
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Zip | 20877
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Country | US
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Telephone | 301-330-4613
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Fax | 301-330-4619
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Provider Business Mailing Address
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Address Line | 9051 SHADY GROVE COURT
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City | GAITHERSBURG
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State | MD
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Zip | 20877
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Country | US
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Telephone | 301-330-4613
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Fax | 301-330-4619
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Authorized Official
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Title or Position | PRESIDENT
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Name | DUY TAM TRAN KIEM
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Credential | DMD
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Telephone | 301-330-4613
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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 | 11662
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License Number State | MD
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