MEDICARE: GEORGE XENAKIS, DDS, MARYLAND, 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	15793	MD

General Provider Information

NPI Number	:	1487029245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGE XENAKIS, DDS, MARYLAND, LLC

Provider Business Mailing Address
First Line	:	10035 BALTIMORE NATIONAL PIKE STE 320
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-3658
Country	:	US
Telephone Number	:	301-241-0123
Fax Number	:	301-241-0125

Provider Business Practice Location Address
First Line	:	10035 BALTIMORE NATIONAL PIKE STE 320
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-3658
Country	:	US
Telephone Number	:	301-241-0123
Fax Number	:	301-241-0125

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GEORGE XENAKIS
Credential	:	D.D.S
Telephone Number	:	212-643-0927

Provider Enumeration Date	:	12/04/2015
Last Update Date	:	05/26/2016

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