Provider Demographics
NPI:1811188014
Name:A GREAT SMILE DENTAL CENTER LLC
Entity Type:Organization
Organization Name:A GREAT SMILE DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
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:
Practice Address - Street 1:7826 EASTERN AVE NW
Practice Address - Street 2:SUITE 301
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1324
Practice Address - Country:US
Practice Address - Phone:202-726-5106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC1000381122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty