Provider Demographics
NPI:1972202711
Name:POTOMAC ORAL AND MAXILLOFACIAL SURGERY; LLC
Entity Type:Organization
Organization Name:POTOMAC ORAL AND MAXILLOFACIAL SURGERY; LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-585-9364
Mailing Address - Street 1:3150 W WARD RD STE 306
Mailing Address - Street 2:
Mailing Address - City:DUNKIRK
Mailing Address - State:MD
Mailing Address - Zip Code:20754-3057
Mailing Address - Country:US
Mailing Address - Phone:410-257-5333
Mailing Address - Fax:410-257-2842
Practice Address - Street 1:3150 W WARD RD STE 306
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:MD
Practice Address - Zip Code:20754-3057
Practice Address - Country:US
Practice Address - Phone:615-585-9364
Practice Address - Fax:410-257-2842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1942407812Medicaid
TN1679626881Medicaid