Provider Demographics
NPI:1861077208
Name:TINY TOOTH PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:TINY TOOTH PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SU
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-812-8027
Mailing Address - Street 1:8032 TROTTERS CHASE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-7592
Mailing Address - Country:US
Mailing Address - Phone:443-812-8027
Mailing Address - Fax:
Practice Address - Street 1:8808 CENTRE PARK DR STE 303
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2224
Practice Address - Country:US
Practice Address - Phone:443-812-8027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty