Provider Demographics
NPI:1164848370
Name:MARYLAND ORAL SURGERY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MARYLAND ORAL SURGERY ASSOCIATES, LLC
Other - Org Name:MARYLAND ORAL SURGERY ASSOCIATES OF FREDERICK, 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 RD.
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850
Mailing Address - Country:US
Mailing Address - Phone:301-340-6884
Mailing Address - Fax:301-340-3836
Practice Address - Street 1:161 THOMAS JOHNSON DR STE 295
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4314
Practice Address - Country:US
Practice Address - Phone:301-698-5208
Practice Address - Fax:301-698-1848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD113471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty