Provider Demographics
NPI:1164245023
Name:VIRTS PEDIATRIC DENTISTRY, LLC
Entity type:Organization
Organization Name:VIRTS PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TRESSLER
Authorized Official - Last Name:VIRTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-606-0672
Mailing Address - Street 1:1 VALLEY VIEW CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21769-8047
Mailing Address - Country:US
Mailing Address - Phone:301-606-0672
Mailing Address - Fax:
Practice Address - Street 1:77 THOMAS JOHNSON DR STE A
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4893
Practice Address - Country:US
Practice Address - Phone:301-682-3887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD63870Medicaid