Provider Demographics
NPI:1144273590
Name:KONZELMAN, JOSEPH LOUIS JR (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:LOUIS
Last Name:KONZELMAN
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 GALYN DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:MD
Mailing Address - Zip Code:21758-9020
Mailing Address - Country:US
Mailing Address - Phone:301-834-6932
Mailing Address - Fax:301-634-6932
Practice Address - Street 1:114 GALYN DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:MD
Practice Address - Zip Code:21758
Practice Address - Country:US
Practice Address - Phone:301-834-6932
Practice Address - Fax:301-834-6932
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0095081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZG9508Medicaid
GAU53580Medicare UPIN
GA19NCBQXMedicare ID - Type UnspecifiedGA MEDICARE