Provider Demographics
NPI:1376861088
Name:BETHANY SERAFIN AWALT, DMD PA
Entity Type:Organization
Organization Name:BETHANY SERAFIN AWALT, DMD PA
Other - Org Name:VALLEY VILLAGE ORAL SURGERY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETHANY
Authorized Official - Middle Name:SERAFIN
Authorized Official - Last Name:AWALT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:410-581-9008
Mailing Address - Street 1:9199 REISTERSTOWN ROAD
Mailing Address - Street 2:SUITE 209B
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117
Mailing Address - Country:US
Mailing Address - Phone:410-581-9008
Mailing Address - Fax:410-581-6720
Practice Address - Street 1:9199 REISTERSTOWN ROAD
Practice Address - Street 2:SUITE 209B
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117
Practice Address - Country:US
Practice Address - Phone:410-581-9008
Practice Address - Fax:410-581-6720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-06
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD48761223S0112X
MD140541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty