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General NPI Number Information
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NPI Number | 1790162998
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Entity Type | Organization
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Legal Business Name | SPECIALIST IN ORTHODONTICS OF MARYLAND, LLC
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Dates
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Enumeration Date | 04/27/2015
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Last Update Date | 12/03/2021
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Provider Practice Location Address
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Address Line | 9812 FALLS ROAD
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City | POTOMAC
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State | MD
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Zip | 20854
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Country | US
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Telephone | 770-692-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 2970 BRANDYWINE RD STE 200
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City | ATLANTA
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State | GA
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Zip | 30341
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Country | US
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Telephone | 770-692-1000
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | JO ANN RICE
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Credential |
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Telephone | 470-881-8679
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 14922
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License Number State | MD
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