NPIMap

Organization Active NPI

Shady Grove Modern Dental PC

  • Dentist
  • Gaithersburg, MD
National Provider Identifier
1508802414
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
11662 Issued in MD
Legal business name
SHADY GROVE MODERN DENTAL PC
Practice address
9051 Shady Grove Court
Gaithersburg, MD 20877
Phone
(301) 330-4613
Fax
(301) 330-4619
NPI assigned
Jun 20, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Duy Tam Tran Kiem, DMDNPI 1992121487
Title
President
Phone
(301) 330-4613

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X 11662 MD Primary

Addresses

Primary practice location

9051 Shady Grove Court
Gaithersburg, MD 20877

Mailing address

9051 Shady Grove Court
Gaithersburg, MD 20877
Phone (301) 330-4613

National Provider Directory

National Provider Directory

Locations

9051 Shady Grove Ct
Gaithersburg, MD 20877
Phone (301) 330-4613

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150761600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1508802414",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9051 SHADY GROVE COURT",
            "city": "GAITHERSBURG",
            "state": "MD",
            "postal_code": "20877",
            "telephone_number": "301-330-4613",
            "fax_number": "301-330-4619"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9051 SHADY GROVE COURT",
            "city": "GAITHERSBURG",
            "state": "MD",
            "postal_code": "20877",
            "telephone_number": "301-330-4613",
            "fax_number": "301-330-4619"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHADY GROVE MODERN DENTAL PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-20",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "TRAN KIEM",
        "authorized_official_first_name": "DUY TAM",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "301-330-4613",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "MD",
            "license": "11662",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Gaithersburg, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.