=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558097477
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROFTON DENTAL CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2022
-----------------------------------------------------
Last Update Date | 07/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1664 VILLAGE GRN
-----------------------------------------------------
City | CROFTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21114-2037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-215-2653
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11523 GREEN ST
-----------------------------------------------------
City | FULTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20759-2665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-660-0060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. RAHAT SOOD
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 301-660-0060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------