Provider Demographics
NPI:1003909011
Name:THE DENTAL GROUP OF FORT WASHINGTON
Entity Type:Organization
Organization Name:THE DENTAL GROUP OF FORT WASHINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-248-3810
Mailing Address - Street 1:2203 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-4228
Mailing Address - Country:US
Mailing Address - Phone:301-390-2575
Mailing Address - Fax:
Practice Address - Street 1:6710 OXON HILL RD
Practice Address - Street 2:SUITE #350
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-1121
Practice Address - Country:US
Practice Address - Phone:301-248-3810
Practice Address - Fax:301-449-6746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD98831223S0112X
DCDEN44661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD=========OtherTIN#
DC654307Medicare ID - Type Unspecified