Provider Demographics
NPI:1275812729
Name:A GREAT SMILE DENTAL CARE PLLC
Entity Type:Organization
Organization Name:A GREAT SMILE DENTAL CARE PLLC
Other - Org Name:WATER BROOK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:SAINT-PHARD
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-726-5106
Mailing Address - Street 1:7826 EASTERN AVE NW
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-1324
Mailing Address - Country:US
Mailing Address - Phone:202-726-5106
Mailing Address - Fax:202-882-0976
Practice Address - Street 1:2750 14TH ST NW
Practice Address - Street 2:C-11
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-6909
Practice Address - Country:US
Practice Address - Phone:202-726-5106
Practice Address - Fax:202-882-0976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN1000381122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD012049900Medicaid
DC037396400Medicaid