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General NPI Number Information
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NPI Number | 1164848370
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Entity Type | Organization
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Legal Business Name | MARYLAND ORAL SURGERY ASSOCIATES, LLC
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Dates
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Enumeration Date | 03/12/2014
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Last Update Date | 08/08/2023
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Provider Practice Location Address
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Address Line | 161 THOMAS JOHNSON DR STE 295
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City | FREDERICK
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State | MD
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Zip | 21702-4314
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Country | US
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Telephone | 301-698-5208
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Fax | 301-698-1848
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Provider Business Mailing Address
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Address Line | 14955 SHADY GROVE RD. SUITE 350
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City | ROCKVILLE
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State | MD
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Zip | 20850
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Country | US
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Telephone | 301-340-6884
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Fax | 301-340-3836
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GLENN A. NATHAN
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Credential | D.D.S.
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Telephone | 301-340-6884
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 11347
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License Number State | MD
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