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General NPI Number Information
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NPI Number | 1821495714
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Entity Type | Organization
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Legal Business Name | STELLAR DENTAL OF HYATTSVILLE, LLC
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Dates
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Enumeration Date | 11/21/2014
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Last Update Date | 11/21/2014
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Provider Practice Location Address
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Address Line | 5813 EASTERN AVE
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City | HYATTSVILLE
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State | MD
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Zip | 20782-2201
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Country | US
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Telephone | 301-754-1900
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Fax |
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Provider Business Mailing Address
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Address Line | 5105 GRIFFENDALE LN
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City | UPPER MARLBORO
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State | MD
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Zip | 20772-3180
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Country | US
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Telephone | 202-203-0230
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. ALLEN GOTORA
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Credential |
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Telephone | 202-203-0230
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 14124
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License Number State | MD
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