Laurel Lakes Pediatric Dentistry, LLC

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

License

13970 Issued in MD

Legal business name

LAUREL LAKES PEDIATRIC DENTISTRY, LLC

Doing business as

Laurel Lakes Pediatric Dentistry

Practice address

13964 Baltimore Ave
Suite C6
Laurel, MD 20707

Phone

(202) 276-0649

Fax

(631) 857-7860

NPI assigned

Jan 27, 2017

Organization subpart

No

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

Authorized official

Name

Antionette C. Wilson, DDS

Title

Owner

Phone

(202) 276-0649

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Laurel Lakes Pediatric Dentistry Doing business as

Locations

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

{
    "created_epoch": "1485475200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1532044800000",
    "number": "1649717638",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "401 CHURCH ST",
            "address_2": "SUITE 2210",
            "city": "NASHVILLE",
            "state": "TN",
            "postal_code": "372192310",
            "telephone_number": "615-988-2627",
            "fax_number": "631-857-7860"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "13964 BALTIMORE AVE",
            "address_2": "SUITE C6",
            "city": "LAUREL",
            "state": "MD",
            "postal_code": "20707",
            "telephone_number": "202-276-0649",
            "fax_number": "631-857-7860"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAUREL LAKES PEDIATRIC DENTISTRY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-01-27",
        "last_updated": "2018-07-20",
        "status": "A",
        "authorized_official_last_name": "WILSON",
        "authorized_official_first_name": "ANTIONETTE",
        "authorized_official_middle_name": "C.",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "202-276-0649",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "MD",
            "license": "13970",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTAL LICENSE",
            "identifier": "13970",
            "state": "MD"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Laurel Lakes Pediatric Dentistry",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Laurel Lakes Pediatric Dentistry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Pediatric Dentistry in Laurel, MD
• Providers in Laurel, MD by specialty
• Pediatric Dentistry in Maryland

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 20, 2018; 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.