Provider Demographics
NPI:1316236813
Name:DECKER & LAVINE, DDS, PA
Entity type:Organization
Organization Name:DECKER & LAVINE, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:301-776-3066
Mailing Address - Street 1:14333 LAUREL BOWIE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-1126
Mailing Address - Country:US
Mailing Address - Phone:301-776-3066
Mailing Address - Fax:301-776-3115
Practice Address - Street 1:14333 LAUREL BOWIE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-1126
Practice Address - Country:US
Practice Address - Phone:301-776-3066
Practice Address - Fax:301-776-3115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD111531223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD950724800Medicaid