Provider Demographics
NPI:1114453610
Name:PRESIDENTIAL PEDIATRIC DENTISTRY & ORTHODONTICS
Entity Type:Organization
Organization Name:PRESIDENTIAL PEDIATRIC DENTISTRY & ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KIDANEMARIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROZARIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-248-6288
Mailing Address - Street 1:350 EASTERN AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-2833
Mailing Address - Country:US
Mailing Address - Phone:202-248-6288
Mailing Address - Fax:202-248-6330
Practice Address - Street 1:350 EASTERN AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-2833
Practice Address - Country:US
Practice Address - Phone:202-248-6288
Practice Address - Fax:202-248-6330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10016431223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC058025400Medicaid