Provider Demographics
NPI:1760654784
Name:ORAL PATHOLOGY SERVICES/MARYLAND ORAL DIAGNOSIS AND THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:ORAL PATHOLOGY SERVICES/MARYLAND ORAL DIAGNOSIS AND THERAPEUTICS, LLC
Other - Org Name:ORAL PATHOLOGY SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DI
Authorized Official - Middle Name:
Authorized Official - Last Name:SUN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PHD
Authorized Official - Phone:301-869-8666
Mailing Address - Street 1:50 W EDMONSTON DR
Mailing Address - Street 2:SUITE 402
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-1228
Mailing Address - Country:US
Mailing Address - Phone:301-838-9033
Mailing Address - Fax:301-838-9148
Practice Address - Street 1:610 PROFESSIONAL DR STE 215
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3439
Practice Address - Country:US
Practice Address - Phone:301-869-8666
Practice Address - Fax:301-869-8677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11508122300000X, 1223P0106X
DC53261223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5486025Medicaid
DCX36809Medicare UPIN
MDU61731Medicare UPIN
MD5486025Medicaid
MD490174Medicare PIN