Provider Demographics
NPI:1881880870
Name:CLARKSBURG DENTAL CENTER
Entity type:Organization
Organization Name:CLARKSBURG DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHUNG
Authorized Official - Middle Name:H
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-515-5525
Mailing Address - Street 1:23212 BREWERS TAVERN WAY
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-4391
Mailing Address - Country:US
Mailing Address - Phone:301-515-5525
Mailing Address - Fax:
Practice Address - Street 1:23212 BREWERS TAVERN WAY
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-4391
Practice Address - Country:US
Practice Address - Phone:301-515-5525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD129881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty