Provider Demographics
NPI:1356855332
Name:ST JUDES DENTAL CLINIC
Entity Type:Organization
Organization Name:ST JUDES DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUK
Authorized Official - Middle Name:E
Authorized Official - Last Name:TAEME
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-226-9338
Mailing Address - Street 1:2802 RHODE ISLAND AVE NE # 1
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-2998
Mailing Address - Country:US
Mailing Address - Phone:202-269-3387
Mailing Address - Fax:202-269-4814
Practice Address - Street 1:2802 RHODE ISLAND AVE NE # 1
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018
Practice Address - Country:US
Practice Address - Phone:202-269-3387
Practice Address - Fax:202-269-4814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-28
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC10010901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty