=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811380363
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY SWANN RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2015
-----------------------------------------------------
Last Update Date | 06/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8472 SIMONDS STREET
-----------------------------------------------------
City | FORT GEORGE MEADE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-677-6078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2658 SHADE BRANCH RD
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21076-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-404-4913
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 5641
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------