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General NPI Number Information
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NPI Number | 1548392152
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Entity Type | Organization
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Legal Business Name | MODEL DENTAL CLINIC
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Dates
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Enumeration Date | 03/09/2007
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Last Update Date | 04/25/2024
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Provider Practice Location Address
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Address Line | 9520 BERGER RD STE 105
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City | COLUMBIA
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State | MD
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Zip | 21046-1554
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Country | US
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Telephone | 410-730-6666
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Fax | 410-730-3501
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Provider Business Mailing Address
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Address Line | 9520 BERGER RD STE 105
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City | COLUMBIA
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State | MD
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Zip | 21046-1554
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Country | US
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Telephone | 410-730-6666
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Fax | 410-730-3501
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | ROGHIEH ATAPOUR
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Credential |
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Telephone | 410-730-6666
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12619
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License Number State | MD
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