=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013345511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ORAL SURGERY CENTER AT MITCHELLVILLE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2013
-----------------------------------------------------
Last Update Date | 10/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12164 CENTRAL AVE STE 224
-----------------------------------------------------
City | MITCHELLVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20721-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-627-1105
-----------------------------------------------------
Fax | 301-627-1105
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12164 CENTRAL AVE STE 224
-----------------------------------------------------
City | MITCHELLVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20721-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-627-1105
-----------------------------------------------------
Fax | 301-627-1105
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MIARI-ANN GRIFFITH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 301-627-1105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 13106
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------