Provider Demographics
NPI:1265768154
Name:WASHINGTON, LATEEFAH TYME (DMD, MS)
Entity type:Individual
Prefix:
First Name:LATEEFAH
Middle Name:TYME
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 S CARRIER PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-5000
Mailing Address - Country:US
Mailing Address - Phone:917-846-5216
Mailing Address - Fax:
Practice Address - Street 1:2630 S CARRIER PKWY STE A
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-5000
Practice Address - Country:US
Practice Address - Phone:917-846-5216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-27
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0139841223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics