Provider Demographics
NPI:1538398797
Name:HAGERTOWN DENTAL CENTER
Entity type:Organization
Organization Name:HAGERTOWN DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHOUDRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-733-2861
Mailing Address - Street 1:301 E ANTIETAM ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-2608
Mailing Address - Country:US
Mailing Address - Phone:301-733-2861
Mailing Address - Fax:301-733-7557
Practice Address - Street 1:301 E ANTIETAM ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-2608
Practice Address - Country:US
Practice Address - Phone:301-733-2861
Practice Address - Fax:301-733-7557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3459122300000X
MD6844122300000X
MD13215122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD019747500Medicaid