Provider Demographics
NPI:1477981926
Name:DIMPLES DENTAL SUITE, PC
Entity Type:Organization
Organization Name:DIMPLES DENTAL SUITE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAKEISHA
Authorized Official - Middle Name:ROCHELLE
Authorized Official - Last Name:PRESSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-297-4592
Mailing Address - Street 1:2811 PENNSYLVANIA AVE SE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-3865
Mailing Address - Country:US
Mailing Address - Phone:202-584-0710
Mailing Address - Fax:202-575-3627
Practice Address - Street 1:2811 PENNSYLVANIA AVE SE
Practice Address - Street 2:SUITE 2
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3865
Practice Address - Country:US
Practice Address - Phone:202-584-0710
Practice Address - Fax:202-575-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-20
Last Update Date:2016-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10007891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC075593600Medicaid