Healthcare Provider Details

I. General information

NPI: 1043542988
Provider Name (Legal Business Name): CENTRAL MARYLAND ORAL AND MAXILLOFACIAL SURGERY P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 CHARTER DR SUITE 330
COLUMBIA MD
21044-3128
US

IV. Provider business mailing address

10710 CHARTER DR SUITE 330
COLUMBIA MD
21044-3128
US

V. Phone/Fax

Practice location:
  • Phone: 410-997-1010
  • Fax: 410-997-0807
Mailing address:
  • Phone: 410-997-1010
  • Fax: 410-997-0807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD0060424
License Number StateMD

VIII. Authorized Official

Name: DOMENICK COLETTI
Title or Position: VICE PRESIDENT
Credential: MD, DDS
Phone: 410-997-1010