Provider Demographics
NPI:1528656600
Name:CROWN & GLORY DENTAL, LLC
Entity type:Organization
Organization Name:CROWN & GLORY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NAKIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:240-754-7425
Mailing Address - Street 1:11479 BERRY RD
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-5957
Mailing Address - Country:US
Mailing Address - Phone:202-425-9618
Mailing Address - Fax:240-754-7425
Practice Address - Street 1:11479 BERRY RD
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-5957
Practice Address - Country:US
Practice Address - Phone:202-425-9618
Practice Address - Fax:240-754-7425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD039376200Medicaid