Healthcare Provider Details

I. General information

NPI: 1346415882
Provider Name (Legal Business Name): MARYLAND ORAL SURGERY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1667 CROFTON CTR SUITE 7A
CROFTON MD
21114-1303
US

IV. Provider business mailing address

14955 SHADY GROVE RD SUITE 330
ROCKVILLE MD
20850-8700
US

V. Phone/Fax

Practice location:
  • Phone: 410-721-0700
  • Fax: 410-721-5459
Mailing address:
  • Phone: 301-340-6884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12859
License Number StateMD

VIII. Authorized Official

Name: MAUREEN PETERSEN
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 301-340-6884