NPIMap

Organization Active NPI

Crown & Glory Dental, LLC

  • General Practice Dentistry
  • Waldorf, MD
National Provider Identifier
1528656600
Registry record updated Jan 5, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
CROWN & GLORY DENTAL, LLC
Practice address
11479 Berry Rd
Waldorf, MD 20603-5957
Phone
(202) 425-9618
Fax
(240) 754-7425
NPI assigned
Jan 5, 2021
Last updated
Jan 5, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 5, 2021

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

Authorized official

Name
Dr. Nakia S. Bush, DDSNPI 1174848667
Title
Dentist/Owner
Phone
(240) 754-7425

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
General Practice Dentistry 1223G0001X Primary

Addresses

Primary practice location

11479 Berry Rd
Waldorf, MD 20603-5957

Mailing address

11479 Berry Rd
Waldorf, MD 20603-5957
Phone (202) 425-9618

Other identifiers 1

IdentifierTypeStateIssuer
039376200MedicaidMD

Electronic endpoints 1

TypeEndpointUseAffiliation
Other URL Waldorf

National Provider Directory

National Provider Directory

Locations

11479 Berry Rd
Waldorf, MD 20603
Phone (202) 425-9618

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": "1609804800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1609804800000",
    "number": "1528656600",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11479 BERRY RD",
            "city": "WALDORF",
            "state": "MD",
            "postal_code": "206035957",
            "telephone_number": "202-425-9618",
            "fax_number": "240-754-7425"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11479 BERRY RD",
            "city": "WALDORF",
            "state": "MD",
            "postal_code": "206035957",
            "telephone_number": "202-425-9618",
            "fax_number": "240-754-7425"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CROWN & GLORY DENTAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-01-05",
        "last_updated": "2021-01-05",
        "certification_date": "2021-01-05",
        "status": "A",
        "authorized_official_last_name": "BUSH",
        "authorized_official_first_name": "NAKIA",
        "authorized_official_middle_name": "S.",
        "authorized_official_title_or_position": "DENTIST/OWNER",
        "authorized_official_telephone_number": "240-754-7425",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "039376200",
            "state": "MD"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "Waldorf",
            "affiliation": "N",
            "address_1": "11479 Berry Rd",
            "city": "Waldorf",
            "state": "MD",
            "country_code": "US",
            "postal_code": "206035957",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Waldorf, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 5, 2021; 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.