Provider Demographics
NPI:1033531280
Name:MARYLAND ORAL SURGERY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MARYLAND ORAL SURGERY ASSOCIATES, LLC
Other - Org Name:MARYLAND ORAL SURGERY ASSOCIATES CROFTON, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:NATHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-340-6884
Mailing Address - Street 1:14955 SHADY GROVE ROAD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-8700
Mailing Address - Country:US
Mailing Address - Phone:301-340-6884
Mailing Address - Fax:301-340-3836
Practice Address - Street 1:2401 BRANDERMILL BLVD.
Practice Address - Street 2:SUITE 320
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054
Practice Address - Country:US
Practice Address - Phone:410-721-0700
Practice Address - Fax:410-721-5459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-07
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD128591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty