Healthcare Provider Details

I. General information

NPI: 1821858937
Provider Name (Legal Business Name): POTOMAC ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 NORTH PRINCE FREDERICK BLVD SUITE 104
PRINCE FREDERICK MD
20678-3057
US

IV. Provider business mailing address

3150 W WARD RD SUITE 306
DUNKIRK MD
20754
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-2416
  • Fax: 443-968-8646
Mailing address:
  • Phone: 410-257-5333
  • Fax: 410-257-2842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: WENDELL GARDNER
Title or Position: OWNER
Credential: DDS
Phone: 410-257-5333