Provider Demographics
NPI:1730435348
Name:STELLAR DENTAL HYATTSVILLE, LLC
Entity type:Organization
Organization Name:STELLAR DENTAL HYATTSVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTORA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-853-1567
Mailing Address - Street 1:5813 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-2201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5813 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-2201
Practice Address - Country:US
Practice Address - Phone:301-853-1567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STELLAR DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD148921223G0001X
MD141241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty