Provider Demographics
NPI:1194949214
Name:MARLA KUSH PROKOP, DMD, PA
Entity type:Organization
Organization Name:MARLA KUSH PROKOP, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:KUSH
Authorized Official - Last Name:PROKOP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:410-897-1931
Mailing Address - Street 1:621 RIDGELY AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1081
Mailing Address - Country:US
Mailing Address - Phone:410-897-1931
Mailing Address - Fax:410-897-1932
Practice Address - Street 1:621 RIDGELY AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1081
Practice Address - Country:US
Practice Address - Phone:410-897-1931
Practice Address - Fax:410-897-1932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD128771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty