Provider Demographics
NPI:1194587386
Name:FAMILY LASER DENTISTRY LLC
Entity type:Organization
Organization Name:FAMILY LASER DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ISHTIAQ
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-817-0681
Mailing Address - Street 1:877 BALTIMORE ANNAPOLIS BLVD STE 305
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-4739
Mailing Address - Country:US
Mailing Address - Phone:410-975-9331
Mailing Address - Fax:
Practice Address - Street 1:877 BALTIMORE ANNAPOLIS BLVD STE 305
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-4739
Practice Address - Country:US
Practice Address - Phone:410-975-9331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental