Provider Demographics
NPI:1710950399
Name:MID-MARYLAND ORAL AND MAXILLOFACIAL SURGERY PA
Entity Type:Organization
Organization Name:MID-MARYLAND ORAL AND MAXILLOFACIAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:M
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSHS
Authorized Official - Phone:301-694-2300
Mailing Address - Street 1:68 THOMAS JOHNSON DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702
Mailing Address - Country:US
Mailing Address - Phone:301-694-2300
Mailing Address - Fax:301-694-7372
Practice Address - Street 1:68 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE A
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702
Practice Address - Country:US
Practice Address - Phone:301-694-2300
Practice Address - Fax:301-694-7372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
733LMedicare PIN