Provider Demographics
NPI:1578735122
Name:GOOD HOPE FAMILY DENTAL
Entity Type:Organization
Organization Name:GOOD HOPE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREJE
Authorized Official - Middle Name:LEGESSE
Authorized Official - Last Name:BEREDED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-581-7600
Mailing Address - Street 1:PO BOX 4129
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-0129
Mailing Address - Country:US
Mailing Address - Phone:202-581-7600
Mailing Address - Fax:
Practice Address - Street 1:2645 NAYLOR RD SE STE 102
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-7255
Practice Address - Country:US
Practice Address - Phone:202-581-7600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10003051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC034492500Medicaid