MEDICARE: MARYLAND LIP AND TONGUE TIE CENTER 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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1164148607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARYLAND LIP AND TONGUE TIE CENTER LLC

Provider Business Mailing Address
First Line	:	8808 CENTRE PARK DR STE 307
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-2126
Country	:	US
Telephone Number	:	443-539-7979
Fax Number	:	443-832-6110

Provider Business Practice Location Address
First Line	:	8808 CENTRE PARK DR STE 307
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-2126
Country	:	US
Telephone Number	:	443-539-7979
Fax Number	:	443-832-6110

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SU KIM
Credential	:	DDS
Telephone Number	:	443-539-7979

Provider Enumeration Date	:	10/17/2022
Last Update Date	:	10/17/2022

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