Healthcare Provider Details

I. General information

NPI: 1164896395
Provider Name (Legal Business Name): GLEN BURNIE ORAL SURGERY ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2015
Last Update Date: 11/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HOSPITAL DR # 237
GLEN BURNIE MD
21061-6902
US

IV. Provider business mailing address

2523 SMITH AVE
BALTIMORE MD
21209-2542
US

V. Phone/Fax

Practice location:
  • Phone: 917-701-3581
  • Fax:
Mailing address:
  • Phone: 917-701-3581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number16083
License Number StateMD

VIII. Authorized Official

Name: DR. SAMAN SOURI
Title or Position: PRESIDENT
Credential: DMD
Phone: 917-701-3581