MEDICARE: BALTIMORE WASHINGTON ENDODONTICS

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	1223E0200X	Endodontics	13345	MD

General Provider Information

NPI Number	:	1275069510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALTIMORE WASHINGTON ENDODONTICS

Provider Business Mailing Address
First Line	:	6021 UNIVERSITY BLVD
Second Line	:	SUITE 170
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-6077
Country	:	US
Telephone Number	:	410-203-1800
Fax Number	:	410-203-1974

Provider Business Practice Location Address
First Line	:	6021 UNIVERSITY BLVD
Second Line	:	SUITE 170
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-6077
Country	:	US
Telephone Number	:	410-203-1800
Fax Number	:	410-203-1974

Authorized Official
Title or Position	:	OFFICE ADMINISTRATIVE ASSISTANT
Name	:	MISS MANDY PALMER
Credential	:
Telephone Number	:	410-203-1800

Provider Enumeration Date	:	05/05/2017
Last Update Date	:	05/05/2017

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