Healthcare Provider Details

I. General information

NPI: 1417861790
Provider Name (Legal Business Name): DMV G-ANGEL SURGICAL ASSIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2453 KENBROOK CT
WALDORF MD
20603-3227
US

IV. Provider business mailing address

2453 KENBROOK CT
WALDORF MD
20603-3227
US

V. Phone/Fax

Practice location:
  • Phone: 301-257-6191
  • Fax:
Mailing address:
  • Phone: 301-257-6191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JACQUES EMILE BUSSIERE
Title or Position: FOUNDER AND MANAGING MEMBER
Credential: LSA, CSA
Phone: 301-257-6191