MEDICARE: BREEZY HILL ORTHO GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	16218	OTHER	MD	DENTAL LICENSE

General Provider Information

NPI Number	:	1073330726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREEZY HILL ORTHO GROUP, LLC

Provider Business Mailing Address
First Line	:	3905 NATIONAL DR STE 340
Second Line	:
City	:	BURTONSVILLE
State	:	MD
Zip	:	20866-6111
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3905 NATIONAL DR STE 340
Second Line	:
City	:	BURTONSVILLE
State	:	MD
Zip	:	20866-6111
Country	:	US
Telephone Number	:	301-857-9096
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ORTHODONTIST
Name	:	DR. LATOYA CALLAHAN
Credential	:	DDS
Telephone Number	:	301-857-9096

Provider Enumeration Date	:	09/24/2024
Last Update Date	:	09/24/2024

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