MEDICARE: TLC MODERN 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	302R00000X	Health Maintenance Organization	15202	MD

General Provider Information

NPI Number	:	1558790154
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TLC MODERN DENTISTRY

Provider Business Mailing Address
First Line	:	18220 CONTOUR RD
Second Line	:
City	:	MONTGOMERY VILLAGE
State	:	MD
Zip	:	20877-2623
Country	:	US
Telephone Number	:	301-208-0002
Fax Number	:

Provider Business Practice Location Address
First Line	:	18220 CONTOUR RD
Second Line	:
City	:	MONTGOMERY VILLAGE
State	:	MD
Zip	:	20877-2623
Country	:	US
Telephone Number	:	301-208-0002
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. ROSANN RODRIGUEZ
Credential	:
Telephone Number	:	301-208-0002

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	11/04/2013

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Directions to “TLC MODERN DENTISTRY ” Practice Location

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