Provider Demographics
NPI:1396249959
Name:MOUNTAIN CITY DENTAL, LLC
Entity type:Organization
Organization Name:MOUNTAIN CITY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOBEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-268-7797
Mailing Address - Street 1:16920 NATIONAL HWY SW
Mailing Address - Street 2:
Mailing Address - City:FROSTBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21532-3306
Mailing Address - Country:US
Mailing Address - Phone:301-689-3677
Mailing Address - Fax:301-689-3477
Practice Address - Street 1:16920 NATIONAL HWY SW
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-3306
Practice Address - Country:US
Practice Address - Phone:301-689-3677
Practice Address - Fax:301-689-3477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16158122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD117263800Medicaid