Healthcare Provider Details

I. General information

NPI: 1013773001
Provider Name (Legal Business Name): SUNRISE ORAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16069 COMPRINT CIR
GAITHERSBURG MD
20877-1321
US

IV. Provider business mailing address

285 W 530 N
VINEYARD UT
84059-4817
US

V. Phone/Fax

Practice location:
  • Phone: 301-762-0062
  • Fax: 301-762-9110
Mailing address:
  • Phone: 949-521-2757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MAX MCCUSKER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 949-521-2757