Healthcare Provider Details

I. General information

NPI: 1598920282
Provider Name (Legal Business Name): MAPLE LAWN ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 01/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7625 MAPLE LAWN BLVD SUITE 240
FULTON MD
20759-2565
US

IV. Provider business mailing address

7625 MAPLE LAWN BLVD SUITE 240
FULTON MD
20759-2565
US

V. Phone/Fax

Practice location:
  • Phone: 301-617-3404
  • Fax: 301-617-3407
Mailing address:
  • Phone: 301-617-3404
  • Fax: 301-617-3407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAY IBRAHIM HADDAD
Title or Position: SOLE MEMBER AND MANAGER
Credential: D.D.S.
Phone: 301-617-3404