Provider Demographics
NPI:1215282611
Name:ANDERSEN DENTAL LLC
Entity type:Organization
Organization Name:ANDERSEN DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-929-1808
Mailing Address - Street 1:1820 LANCASTER ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-3584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1820 LANCASTER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-3584
Practice Address - Country:US
Practice Address - Phone:410-929-1808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-21
Last Update Date:2012-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD150891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty