=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538398797
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAGERTOWN DENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2009
-----------------------------------------------------
Last Update Date | 07/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 E ANTIETAM ST
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21740-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-733-2861
-----------------------------------------------------
Fax | 301-733-7557
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 E ANTIETAM ST
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21740-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-733-2861
-----------------------------------------------------
Fax | 301-733-7557
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. VIC A CHOUDRY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 301-733-2861
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3459
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6844
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 13215
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------