MEDICARE: SL SAMPLE DDS 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1164156972
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SL SAMPLE DDS LLC

Provider Business Mailing Address
First Line	:	10500 NORBOURNE FARM RD
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-4696
Country	:	US
Telephone Number	:	662-374-6450
Fax Number	:

Provider Business Practice Location Address
First Line	:	6339 ALLENTOWN RD STE E
Second Line	:
City	:	CAMP SPRINGS
State	:	MD
Zip	:	20748-2600
Country	:	US
Telephone Number	:	301-449-2800
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	SHEMIKA SAMPLE
Credential	:	DDS
Telephone Number	:	662-374-6450

Provider Enumeration Date	:	07/16/2022
Last Update Date	:	07/16/2022

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Directions to “SL SAMPLE DDS LLC ” Practice Location

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