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General NPI Number Information
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NPI Number | 1013360858
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Entity Type | Organization
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Legal Business Name | AVIE ORAL SURGERY GROUP
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Dates
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Enumeration Date | 07/17/2016
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Last Update Date | 02/15/2023
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Provider Practice Location Address
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Address Line | 1215 ANNAPOLIS RD SUITE 205
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City | ODENTON
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State | MD
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Zip | 21113-1344
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Country | US
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Telephone | 678-982-5136
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Fax |
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Provider Business Mailing Address
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Address Line | 1215 ANNAPOLIS RD STE 205
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City | ODENTON
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State | MD
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Zip | 21113-1346
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Country | US
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Telephone | 678-982-5136
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EDNA BUCKLE
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Credential |
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Telephone | 678-982-5136
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 14775
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License Number State | MD
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