MEDICARE: MY ELLICOTT CITY DENTIST 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1689283681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY ELLICOTT CITY DENTIST LLC

Provider Business Mailing Address
First Line	:	10050 BALTIMORE NATIONAL PIKE STE F110
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-3668
Country	:	US
Telephone Number	:	410-480-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	10050 BALTIMORE NATIONAL PIKE STE F110
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-3668
Country	:	US
Telephone Number	:	410-480-2000
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. CYRUS ALLAFI
Credential	:	DDS
Telephone Number	:	410-480-2000

Provider Enumeration Date	:	07/26/2020
Last Update Date	:	11/28/2021

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