Provider Demographics
NPI:1821858937
Name:POTOMAC ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:POTOMAC ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-257-5333
Mailing Address - Street 1:3150 W WARD RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:DUNKIRK
Mailing Address - State:MD
Mailing Address - Zip Code:20754
Mailing Address - Country:US
Mailing Address - Phone:410-257-5333
Mailing Address - Fax:410-257-2842
Practice Address - Street 1:955 NORTH PRINCE FREDERICK BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3057
Practice Address - Country:US
Practice Address - Phone:410-535-2416
Practice Address - Fax:443-968-8646
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POTOMAC ORAL & MAXILLOFACIAL SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD215149900Medicaid