Provider Demographics
NPI:1952961492
Name:DEBONAIR DENTAL DC PLLC
Entity Type:Organization
Organization Name:DEBONAIR DENTAL DC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-232-1116
Mailing Address - Street 1:2737 DEVONSHIRE PL NW STE A
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-3479
Mailing Address - Country:US
Mailing Address - Phone:202-232-1116
Mailing Address - Fax:202-232-1911
Practice Address - Street 1:2737 DEVONSHIRE PL NW STE A
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-3479
Practice Address - Country:US
Practice Address - Phone:202-232-1116
Practice Address - Fax:202-232-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCDEN1001405OtherDOH HEALTH REGULATION AND LICENSING ADMINISTRATION BOARD OF DENTISTRY