Provider Demographics
NPI:1689885998
Name:GOLLY, ADRIANNE L (MD)
Entity Type:Individual
Prefix:
First Name:ADRIANNE
Middle Name:L
Last Name:GOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ADRIANNE
Other - Middle Name:L
Other - Last Name:GOLLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:198 THOMAS JOHNSON DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4398
Mailing Address - Country:US
Mailing Address - Phone:301-694-0870
Mailing Address - Fax:301-694-7034
Practice Address - Street 1:198 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4398
Practice Address - Country:US
Practice Address - Phone:301-694-0870
Practice Address - Fax:301-694-7034
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN96431223S0112X
TN50224204E00000X
MD156361223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1531915Medicaid