MEDICARE: A GREAT SMILE DENTAL CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	1000381	DC

General Provider Information

NPI Number	:	1811188014
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A GREAT SMILE DENTAL CENTER LLC

Provider Business Mailing Address
First Line	:	7826 EASTERN AVE NW
Second Line	:	SUITE 301
City	:	WASHINGTON
State	:	DC
Zip	:	20012-1324
Country	:	US
Telephone Number	:	202-726-5106
Fax Number	:

Provider Business Practice Location Address
First Line	:	7826 EASTERN AVE NW
Second Line	:	SUITE 301
City	:	WASHINGTON
State	:	DC
Zip	:	20012-1324
Country	:	US
Telephone Number	:	202-726-5106
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. MARLENE SAINT PHARD SHAW
Credential	:	DDS
Telephone Number	:	202-726-5106

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	08/05/2007

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