Healthcare Provider Details

I. General information

NPI: 1649264466
Provider Name (Legal Business Name): JAY SAHARAT NOKKEO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 N FREDERICK AVE 2ND FLOOR
GAITHERSBURG MD
20877-2506
US

IV. Provider business mailing address

507 N FREDERICK AVE 2ND FLOOR
GAITHERSBURG MD
20877-2506
US

V. Phone/Fax

Practice location:
  • Phone: 301-926-4800
  • Fax: 301-926-4899
Mailing address:
  • Phone: 301-926-4800
  • Fax: 301-926-4899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13271
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN6006
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number13271
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: