Provider Demographics
NPI:1033402136
Name:SAINT ELIZABETHS HOSPITAL DENTAL CLINIC
Entity Type:Organization
Organization Name:SAINT ELIZABETHS HOSPITAL DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:CANAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:202-299-5500
Mailing Address - Street 1:1100 ALABAMA AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-4540
Mailing Address - Country:US
Mailing Address - Phone:202-299-5610
Mailing Address - Fax:
Practice Address - Street 1:1100 ALABAMA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4540
Practice Address - Country:US
Practice Address - Phone:202-299-5610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT ELIZABETHS HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHFD01-0230261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental