Provider Demographics
NPI:1851861199
Name:ABYSSINIA DENTAL LLC
Entity Type:Organization
Organization Name:ABYSSINIA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREJEW
Authorized Official - Middle Name:KIFLE
Authorized Official - Last Name:TESSEMA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-477-1005
Mailing Address - Street 1:4041 POWDER MILL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3106
Mailing Address - Country:US
Mailing Address - Phone:301-477-1005
Mailing Address - Fax:
Practice Address - Street 1:4041 POWDER MILL RD STE 100
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-3106
Practice Address - Country:US
Practice Address - Phone:301-477-1005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD131458100Medicaid
DC17075979Medicaid