=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972722114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHESAPEAKE FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1610 WEST ST SUITE 202
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-4055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-990-4800
-----------------------------------------------------
Fax | 410-990-4869
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1610 WEST ST SUITE 202
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-4055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-990-4800
-----------------------------------------------------
Fax | 410-990-4869
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DEBORAH ANN CARUSO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 410-990-4800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10561
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------