Provider Demographics
NPI:1164548335
Name:ORAL AND MAXILLOFACIAL SURGERY SPECIALISTS PC
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRILLON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:301-564-1400
Mailing Address - Street 1:10215 FERNWOOD RD
Mailing Address - Street 2:SUITE 510
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-1106
Mailing Address - Country:US
Mailing Address - Phone:301-564-1400
Mailing Address - Fax:301-564-1413
Practice Address - Street 1:10215 FERNWOOD RD
Practice Address - Street 2:SUITE 510
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-1106
Practice Address - Country:US
Practice Address - Phone:301-564-1400
Practice Address - Fax:301-564-1413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD115951800Medicaid
MD6374780001OtherP10
MD104427Medicare PIN
MD6374780001OtherP10