Provider Demographics
NPI:1912363573
Name:FIDEL DENTAL GROUP, PLLC
Entity Type:Organization
Organization Name:FIDEL DENTAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-362-7413
Mailing Address - Street 1:4400 JENIFER ST NW
Mailing Address - Street 2:SUITE 335
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-2113
Mailing Address - Country:US
Mailing Address - Phone:202-362-7413
Mailing Address - Fax:
Practice Address - Street 1:4400 JENIFER ST NW
Practice Address - Street 2:SUITE 335
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015-2113
Practice Address - Country:US
Practice Address - Phone:202-362-7413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10012961223G0001X
DCDEN58861223P0221X
DCDEN56691223P0300X
DCDEN10005701223P0700X
DCDEN10003551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty