MEDICARE: PEDIATRIC DENTISTRY

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1124892344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	23140 MOAKLEY ST STE 3
Second Line	:
City	:	LEONARDTOWN
State	:	MD
Zip	:	20650-2923
Country	:	US
Telephone Number	:	301-997-1800
Fax Number	:	301-997-0402

Provider Business Practice Location Address
First Line	:	23140 MOAKLEY ST STE 3
Second Line	:
City	:	LEONARDTOWN
State	:	MD
Zip	:	20650-2923
Country	:	US
Telephone Number	:	301-997-1800
Fax Number	:	301-997-0402

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOSE JUAMBELTZ
Credential	:	DDS
Telephone Number	:	410-257-7676

Provider Enumeration Date	:	11/08/2023
Last Update Date	:	11/08/2023

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Directions to “PEDIATRIC DENTISTRY ” Practice Location

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