Provider Demographics
NPI:1962780916
Name:JEAN-DANIEL BRUTUS D.D.S., LLC
Entity type:Organization
Organization Name:JEAN-DANIEL BRUTUS D.D.S., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN-DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUTUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-262-1112
Mailing Address - Street 1:6000 LAUREL BOWIE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4000
Mailing Address - Country:US
Mailing Address - Phone:301-262-1112
Mailing Address - Fax:301-262-2237
Practice Address - Street 1:6000 LAUREL BOWIE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4000
Practice Address - Country:US
Practice Address - Phone:301-262-1112
Practice Address - Fax:301-262-2237
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEMMERTON FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD136731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4108761Medicaid