MEDICARE: PEDIATRIC DENTAL CARE, 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	1223P0221X	Pediatric Dentistry	11552	MD

General Provider Information

NPI Number	:	1639554876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC DENTAL CARE, LLC

Provider Business Mailing Address
First Line	:	1011 E PATRICK ST
Second Line	:
City	:	FREDERICK
State	:	MD
Zip	:	21701-3119
Country	:	US
Telephone Number	:	301-360-9692
Fax Number	:	301-668-9692

Provider Business Practice Location Address
First Line	:	1011 E PATRICK ST
Second Line	:
City	:	FREDERICK
State	:	MD
Zip	:	21701-3119
Country	:	US
Telephone Number	:	301-360-9692
Fax Number	:	301-668-9692

Authorized Official
Title or Position	:	PEDIATRIC DENTIST
Name	:	FARIBA PARYAVI
Credential	:	DDS
Telephone Number	:	301-360-9692

Provider Enumeration Date	:	07/29/2015
Last Update Date	:	07/29/2015

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