Healthcare Provider Details

I. General information

NPI: 1457913907
Provider Name (Legal Business Name): AKESO OROFACIAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13934 BALTIMORE AVE
LAUREL MD
20707-5000
US

IV. Provider business mailing address

13934 BALTIMORE AVE
LAUREL MD
20707-5000
US

V. Phone/Fax

Practice location:
  • Phone: 301-329-5758
  • Fax: 410-665-3235
Mailing address:
  • Phone: 301-329-5758
  • Fax: 410-665-3235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. TREVANN LYN
Title or Position: OWNER
Credential: DMD
Phone: 301-329-5758