=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972035939
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUMMER ROSE CERAOLO-O'DONNELL DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2017
-----------------------------------------------------
Last Update Date | 02/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1134 N ROLLING RD
-----------------------------------------------------
City | CATONSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21228-3931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-788-4555
-----------------------------------------------------
Fax | 410-744-0142
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1134 N ROLLING RD
-----------------------------------------------------
City | CATONSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21228-3931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-788-4555
-----------------------------------------------------
Fax | 410-744-0142
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | LL837
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 16913
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------