Provider Demographics
NPI:1548536949
Name:OCTAVIA SIMKINS-WISEMAN DDS PC
Entity type:Organization
Organization Name:OCTAVIA SIMKINS-WISEMAN DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OCTAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMKINS-WISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:240-393-9861
Mailing Address - Street 1:12150 ANNAPOLIS ROAD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769
Mailing Address - Country:US
Mailing Address - Phone:301-249-2862
Mailing Address - Fax:301-249-4958
Practice Address - Street 1:12150 ANNAPOLIS ROAD
Practice Address - Street 2:SUITE 301
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769
Practice Address - Country:US
Practice Address - Phone:301-249-8000
Practice Address - Fax:301-249-4958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10983122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty