Provider Demographics
NPI:1356331953
Name:CENTER FOR ORAL & MAXILLOFACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:CENTER FOR ORAL & MAXILLOFACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:CAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-337-7755
Mailing Address - Street 1:1212 YORK RD
Mailing Address - Street 2:SUITE A201
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6240
Mailing Address - Country:US
Mailing Address - Phone:410-337-7755
Mailing Address - Fax:410-337-7922
Practice Address - Street 1:1212 YORK RD
Practice Address - Street 2:SUITE A201
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6240
Practice Address - Country:US
Practice Address - Phone:410-337-7755
Practice Address - Fax:410-337-7922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1162261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD138487Medicare UPIN
MD21C0001162Medicare Oscar/Certification