Provider Demographics
NPI:1194964015
Name:NORTHWEST DENTAL INC
Entity type:Organization
Organization Name:NORTHWEST DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:B
Authorized Official - Last Name:SUROSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-486-5580
Mailing Address - Street 1:4821 BUTLER ROAD
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:GLYNDON
Mailing Address - State:MD
Mailing Address - Zip Code:21071
Mailing Address - Country:US
Mailing Address - Phone:410-486-5580
Mailing Address - Fax:410-484-6365
Practice Address - Street 1:4821 BUTLER ROAD
Practice Address - Street 2:SUITE 2B
Practice Address - City:GLYNDON
Practice Address - State:MD
Practice Address - Zip Code:21071
Practice Address - Country:US
Practice Address - Phone:410-486-5580
Practice Address - Fax:410-484-6365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD7474261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental