Provider Demographics
NPI:1699426668
Name:PEDIATRIC DENTAL GROUP,LLC
Entity type:Organization
Organization Name:PEDIATRIC DENTAL GROUP,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:TOFIGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-793-1288
Mailing Address - Street 1:19610 CLUB HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20886-3035
Mailing Address - Country:US
Mailing Address - Phone:301-793-1288
Mailing Address - Fax:
Practice Address - Street 1:19610 CLUB HOUSE RD
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20886-3035
Practice Address - Country:US
Practice Address - Phone:301-793-1288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty