=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720562507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARUNDEL PEDIATRIC DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2018
-----------------------------------------------------
Last Update Date | 09/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8531 VETERANS HWY STE 103
-----------------------------------------------------
City | MILLERSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21108-2653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-987-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8531 VETERANS HWY STE 103
-----------------------------------------------------
City | MILLERSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21108-2653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-987-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRIC DENTIST/OWNER
-----------------------------------------------------
Name | DR. MAHTAB KHOSHKHOU
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 443-904-2459
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------