Provider Demographics
NPI:1649676503
Name:MONTGOMERY ORAL & FACIAL SURGERY, LLC
Entity type:Organization
Organization Name:MONTGOMERY ORAL & FACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:MERLO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:301-468-0020
Mailing Address - Street 1:4701 RANDOLPH RD
Mailing Address - Street 2:SUITE G-10
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2257
Mailing Address - Country:US
Mailing Address - Phone:301-468-0020
Mailing Address - Fax:301-468-2304
Practice Address - Street 1:4701 RANDOLPH RD
Practice Address - Street 2:SUITE G-10
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-2257
Practice Address - Country:US
Practice Address - Phone:301-468-0020
Practice Address - Fax:301-468-2304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD118221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty