Provider Demographics
NPI:1710436407
Name:CENTRAL MARYLAND ORAL AND FACIAL SURGICAL ARTS OF CLARKSVILLE, LLC
Entity Type:Organization
Organization Name:CENTRAL MARYLAND ORAL AND FACIAL SURGICAL ARTS OF CLARKSVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:CARTER
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-293-7339
Mailing Address - Street 1:12431 CLARKSVILLE PIKE, ROUTE 108
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029
Mailing Address - Country:US
Mailing Address - Phone:562-293-7339
Mailing Address - Fax:
Practice Address - Street 1:12431 CLARKSVILLE PIKE, ROUTE 108
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21029
Practice Address - Country:US
Practice Address - Phone:562-293-7339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD155591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty