Healthcare Provider Details

I. General information

NPI: 1689885998
Provider Name (Legal Business Name): ADRIANNE L GOLLY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ADRIANNE L GOLLY DDS

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 THOMAS JOHNSON DR SUITE 101
FREDERICK MD
21702-4398
US

IV. Provider business mailing address

198 THOMAS JOHNSON DR SUITE 101
FREDERICK MD
21702-4398
US

V. Phone/Fax

Practice location:
  • Phone: 301-694-0870
  • Fax: 301-694-7034
Mailing address:
  • Phone: 301-694-0870
  • Fax: 301-694-7034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9643
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number50224
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number15636
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: