Provider Demographics
NPI:1487759361
Name:THE KID'S DENTIST, P.A.
Entity type:Organization
Organization Name:THE KID'S DENTIST, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NNEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:443-622-8908
Mailing Address - Street 1:7230 LEE DEFOREST DR
Mailing Address - Street 2:STE 107N
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-3202
Mailing Address - Country:US
Mailing Address - Phone:443-622-8908
Mailing Address - Fax:443-819-1659
Practice Address - Street 1:7230 LEE DEFOREST DR
Practice Address - Street 2:STE 107N
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-3202
Practice Address - Country:US
Practice Address - Phone:443-622-8908
Practice Address - Fax:443-819-1659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223P0221X
MD125061223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD025585800Medicaid