Provider Demographics
NPI:1891039988
Name:WASHINGTON ORAL SURGERY CENTER, LLC
Entity type:Organization
Organization Name:WASHINGTON ORAL SURGERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKO
Authorized Official - Middle Name:
Authorized Official - Last Name:NKUNGULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-341-0041
Mailing Address - Street 1:1401 MERCANTILE LN
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-4301
Mailing Address - Country:US
Mailing Address - Phone:301-341-0041
Mailing Address - Fax:
Practice Address - Street 1:1401 MERCANTILE LN
Practice Address - Street 2:SUITE 102
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-4301
Practice Address - Country:US
Practice Address - Phone:301-341-0041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14426261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery