FORM 1023-EZ for MARYLAND DENTAL IMPLANT STUDY CLUB CORPORATION

Field Data
EIN 47-2421272
Case Number EO-2017237-000286
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name MARYLAND DENTAL IMPLANT STUDY CLUB CORPORATION
Organization’s Mailing Address 77 WASHINGTON ST
City ROCKVILLE
State MD
ZIP 20850-2335
Accounting period End 12
Primary contact name SAM BULBIN
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $275.00
Officer/Director/Trustee One

SIVAKUMAR SREENIVASAN
PRESIDENT
77 WASHINGTON ST
ROCKVILLE MD 20850-2335

Officer/Director/Trustee Two

USA BUNNAG
SECRETARY
6501 DEMOCRACY BLVD
BETHESDA MD 20817-1685

Officer/Director/Trustee Three

BEHRAM J DALAL
DIRECTOR
12450 PARKLAWN DR
ROCKVILLE MD 20852-1729

Organization’s website
Organization’s email
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 12/1/2014
Organization Incorporation State MD
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code E60 - Health Support Services
Organization’s purpose Charitable: Yes
Religious: No
Educational: Yes
Scientific: Yes
Literary: No
Public Safety: No
Amateur Sports: No
Cruelty Prevention: No
Qualify For Exemption No
Legislation influence No
Compensation of Officer director trustee No
Donation of funds No
Conducting Activities Outside of United States No
Financial transactions with officers No
Unrelated Gross Income $1,000 or More No
Gaming Activity No
Disaster relief assistance No
One Third Support Public No
One Third Support Gifts Yes
Benefit of College No
Private Foundation 508(e) No
Seeking Retroactive Reinstatement No
Seeking Section 7 Reinstatement Yes
Correctness Declaration Yes
Signature Name
Signature Title
Signature Date

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