Healthcare Provider Details

I. General information

NPI: 1821693300
Provider Name (Legal Business Name): EVOLUTION ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19851 OBSERVATION DR STE 320
GERMANTOWN MD
20876-4143
US

IV. Provider business mailing address

19851 OBSERVATION DR STE 320
GERMANTOWN MD
20876-4143
US

V. Phone/Fax

Practice location:
  • Phone: 301-916-6000
  • Fax: 301-916-6113
Mailing address:
  • Phone: 301-916-6000
  • Fax: 301-916-6113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JAMES RYAN
Title or Position: ORAL SURGEON/OWNER
Credential: DDS
Phone: 301-916-6000