Healthcare Provider Details

I. General information

NPI: 1770694523
Provider Name (Legal Business Name): MARYLAND ORAL SURGERY ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/09/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14333 LAUREL BOWIE ROAD SUITE 205
LAUREL MD
20708
US

IV. Provider business mailing address

14955 SHADY GROVE ROAD SUITE 350
ROCKVILLE MD
20850-8700
US

V. Phone/Fax

Practice location:
  • Phone: 301-953-1888
  • Fax: 301-953-1891
Mailing address:
  • Phone: 301-340-6884
  • Fax: 301-340-3836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. GLENN A NATHAN
Title or Position: PRESIDENT OF MARYLAND ORAL SURGERY
Credential: D.D.S.
Phone: 301-340-6884