Provider Demographics
NPI:1306642848
Name:SMALLTOWNE DENTAL LLC
Entity type:Organization
Organization Name:SMALLTOWNE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEMION
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNWALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-436-2195
Mailing Address - Street 1:6620 CRAIN HWY STE 204
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-4273
Mailing Address - Country:US
Mailing Address - Phone:301-870-3966
Mailing Address - Fax:301-753-1992
Practice Address - Street 1:6620 CRAIN HWY STE 204
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-4273
Practice Address - Country:US
Practice Address - Phone:301-870-3966
Practice Address - Fax:301-753-1992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-24
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental