Healthcare Provider Details

I. General information

NPI: 1942573860
Provider Name (Legal Business Name): MONTGOMERY ORAL & FACIAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2012
Last Update Date: 02/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 RANDOLPH RD G10
ROCKVILLE MD
20852-2257
US

IV. Provider business mailing address

4701 RANDOLPH RD G10
ROCKVILLE MD
20852-2257
US

V. Phone/Fax

Practice location:
  • Phone: 301-468-0020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11822
License Number StateMD

VIII. Authorized Official

Name: DR. LEONARD MERLO
Title or Position: OWNER
Credential:
Phone: 301-468-0020