Provider Demographics
NPI:1053715268
Name:LAUREL PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:LAUREL PEDIATRIC DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTISTRY
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:STOVALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:240-441-2193
Mailing Address - Street 1:13916 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5009
Mailing Address - Country:US
Mailing Address - Phone:301-498-6511
Mailing Address - Fax:
Practice Address - Street 1:13916 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5009
Practice Address - Country:US
Practice Address - Phone:301-498-6511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty