Provider Demographics
NPI:1053602953
Name:MARYLAND AVENUE PERIODONTICS, LLC
Entity type:Organization
Organization Name:MARYLAND AVENUE PERIODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-242-2588
Mailing Address - Street 1:6520 N 7TH AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-1158
Mailing Address - Country:US
Mailing Address - Phone:602-242-2588
Mailing Address - Fax:602-242-3137
Practice Address - Street 1:6520 N 7TH AVE STE 5
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-1158
Practice Address - Country:US
Practice Address - Phone:602-242-2588
Practice Address - Fax:602-242-3137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty