Provider Demographics
NPI:1962914507
Name:KIDS BY THE BAY DENTAL LLC
Entity type:Organization
Organization Name:KIDS BY THE BAY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANNON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:240-776-2203
Mailing Address - Street 1:5010 REGENCY PLACE STE 102
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695
Mailing Address - Country:US
Mailing Address - Phone:240-776-2203
Mailing Address - Fax:
Practice Address - Street 1:5010 REGENCY PLACE STE 102
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695
Practice Address - Country:US
Practice Address - Phone:240-776-2203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX6939Medicaid