=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336002740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE STUDIO - TMJ & MAXILLOFACIAL SURGERY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2025
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 ELDEN STREET UNIT 22 AND 23
-----------------------------------------------------
City | HERNDON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-542-1267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24500 RIDGE RD
-----------------------------------------------------
City | DAMASCUS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-542-1267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / MANAGING MEMBER
-----------------------------------------------------
Name | DR. LEONEL PEREZ JR.
-----------------------------------------------------
Credential | DDS, MD, FACS
-----------------------------------------------------
Telephone | 210-542-1267
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------