Provider Demographics
NPI:1821693300
Name:EVOLUTION ORAL SURGERY
Entity Type:Organization
Organization Name:EVOLUTION ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-916-6000
Mailing Address - Street 1:19851 OBSERVATION DR STE 320
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-4143
Mailing Address - Country:US
Mailing Address - Phone:301-916-6000
Mailing Address - Fax:301-916-6113
Practice Address - Street 1:19851 OBSERVATION DR STE 320
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-4143
Practice Address - Country:US
Practice Address - Phone:301-916-6000
Practice Address - Fax:301-916-6113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1356508493Medicaid