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General NPI Number Information
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NPI Number | 1649489352
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Entity Type | Organization
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Legal Business Name | PETERSON & REDDY, D.D.S., P.A.
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 11855 HOLLY LN SUITE 103
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City | WALDORF
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State | MD
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Zip | 20601-3114
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Country | US
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Telephone | 301-843-3367
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Fax |
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Provider Business Mailing Address
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Address Line | 11855 HOLLY LN SUITE 103
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City | WALDORF
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State | MD
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Zip | 20601-3114
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VICE-PRESIDENT
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Name | DR. AJAY REDDY
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Credential | D.D.S.
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Telephone | 301-843-3367
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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 | 12834
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License Number State | MD
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