Provider Demographics
NPI:1396507588
Name:BURWOOD VILLAGE DENTISTRY LLC
Entity type:Organization
Organization Name:BURWOOD VILLAGE DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ISHTIAQ
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-817-0681
Mailing Address - Street 1:1608 W FURNACE BRANCH RD STE A
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-1411
Mailing Address - Country:US
Mailing Address - Phone:410-859-1038
Mailing Address - Fax:
Practice Address - Street 1:1608 W FURNACE BRANCH RD STE A
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-1411
Practice Address - Country:US
Practice Address - Phone:410-859-1038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental