Provider Demographics
NPI:1013360858
Name:AVIE ORAL SURGERY GROUP
Entity Type:Organization
Organization Name:AVIE ORAL SURGERY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-982-5136
Mailing Address - Street 1:1215 ANNAPOLIS RD STE 205
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1346
Mailing Address - Country:US
Mailing Address - Phone:678-982-5136
Mailing Address - Fax:
Practice Address - Street 1:1215 ANNAPOLIS RD
Practice Address - Street 2:SUITE 205
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1344
Practice Address - Country:US
Practice Address - Phone:678-982-5136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-17
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD147751223S0112X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty