Provider Demographics
NPI:1922738848
Name:SHININGSTARS PEDIATRIC DENTISTRY PC
Entity Type:Organization
Organization Name:SHININGSTARS PEDIATRIC DENTISTRY PC
Other - Org Name:SHININGSTARS PEDIATRIC DENTISTRY VAN NESS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:CUC
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-600-4833
Mailing Address - Street 1:PO BOX 10083
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-8083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4301 CONNECTICUT AVE NW STE 453
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-2356
Practice Address - Country:US
Practice Address - Phone:202-470-3676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHININGSTARS PEDIATRIC DENTISTRY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty