Provider Demographics
NPI:1851422893
Name:SUROSKY, PHILLIP BARRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:BARRY
Last Name:SUROSKY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4821 BUTLER ROAD
Mailing Address - Street 2:2B
Mailing Address - City:GLYNDON
Mailing Address - State:MD
Mailing Address - Zip Code:21071
Mailing Address - Country:US
Mailing Address - Phone:410-833-6200
Mailing Address - Fax:410-833-6365
Practice Address - Street 1:4821 BUTLER ROAD
Practice Address - Street 2:2B
Practice Address - City:GLYNDON
Practice Address - State:MD
Practice Address - Zip Code:21071
Practice Address - Country:US
Practice Address - Phone:410-833-6200
Practice Address - Fax:410-833-6365
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD7474122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD521400959OtherTAX ID