Provider Demographics
NPI:1942825989
Name:DALE, KONDO K
Entity Type:Individual
Prefix:
First Name:KONDO
Middle Name:K
Last Name:DALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92035
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20090-2035
Mailing Address - Country:US
Mailing Address - Phone:202-615-1078
Mailing Address - Fax:
Practice Address - Street 1:1160 1ST ST NE APT 308
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4699
Practice Address - Country:US
Practice Address - Phone:202-615-1078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker