Provider Demographics
NPI:1114421062
Name:DENTAL HEALTH OF DC PLLC
Entity Type:Organization
Organization Name:DENTAL HEALTH OF DC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTEL
Authorized Official - Middle Name:GRETA
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-562-6340
Mailing Address - Street 1:3130 MARTIN LUTHER KING JR AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-1503
Mailing Address - Country:US
Mailing Address - Phone:202-562-6340
Mailing Address - Fax:202-562-6342
Practice Address - Street 1:3130 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-1503
Practice Address - Country:US
Practice Address - Phone:202-562-6340
Practice Address - Fax:202-562-6342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC=========Medicaid