Provider Demographics
NPI:1326159179
Name:MARYLAND ORAL SURGERY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MARYLAND ORAL SURGERY ASSOCIATES, LLC
Other - Org Name:MARYLAND ORAL SURGERY ASSOCIATES, PA
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 1:14955 SHADY GROVE ROAD
Practice Address - Street 2:SUITE 330
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-8700
Practice Address - Country:US
Practice Address - Phone:301-340-0101
Practice Address - Fax:301-340-1689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G01526Medicare ID - Type UnspecifiedGROUP NUMBER