Provider Demographics
NPI:1679819098
Name:ELITE DENTAL TAKOMA PARK
Entity Type:Organization
Organization Name:ELITE DENTAL TAKOMA PARK
Other - Org Name:GEORGIA AVENUE DENTAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALFANI
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:202-723-8284
Mailing Address - Street 1:6925 WILLOW STREET NW.
Mailing Address - Street 2:SUITE#B106
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-2000
Mailing Address - Country:US
Mailing Address - Phone:202-723-8284
Mailing Address - Fax:202-882-1127
Practice Address - Street 1:6925 WILLOW STREET NW.
Practice Address - Street 2:SUITE#B106
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-2000
Practice Address - Country:US
Practice Address - Phone:202-723-8284
Practice Address - Fax:202-882-1127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-13
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD145251223G0001X
DC261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1942468590OtherINDIVIDUAL NPI NUMBER