Healthcare Provider Details

I. General information

NPI: 1760654784
Provider Name (Legal Business Name): ORAL PATHOLOGY SERVICES/MARYLAND ORAL DIAGNOSIS AND THERAPEUTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 PROFESSIONAL DR STE 215
GAITHERSBURG MD
20879-3439
US

IV. Provider business mailing address

50 W EDMONSTON DR SUITE 402
ROCKVILLE MD
20852-1228
US

V. Phone/Fax

Practice location:
  • Phone: 301-869-8666
  • Fax: 301-869-8677
Mailing address:
  • Phone: 301-838-9033
  • Fax: 301-838-9148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number11508
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number5326
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number11508
License Number StateMD

VIII. Authorized Official

Name: DR. DI SUN
Title or Position: DIRECTOR
Credential: DDS PHD
Phone: 301-869-8666