Healthcare Provider Details

I. General information

NPI: 1013360858
Provider Name (Legal Business Name): AVIE ORAL SURGERY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2016
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 ANNAPOLIS RD SUITE 205
ODENTON MD
21113-1344
US

IV. Provider business mailing address

1215 ANNAPOLIS RD STE 205
ODENTON MD
21113-1346
US

V. Phone/Fax

Practice location:
  • Phone: 678-982-5136
  • Fax:
Mailing address:
  • Phone: 678-982-5136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number14775
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. EDNA BUCKLE
Title or Position: PRESIDENT
Credential:
Phone: 678-982-5136