MEDICARE: GEORGETOWN ORTHODONTICS, PLLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1972735017	OTHER		DOCTOR NPI

General Provider Information

NPI Number	:	1881261907
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGETOWN ORTHODONTICS, PLLC

Provider Business Mailing Address
First Line	:	4434 MACARTHUR BLVD NW STE 201
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20007-2550
Country	:	US
Telephone Number	:	202-333-2200
Fax Number	:	202-333-2260

Provider Business Practice Location Address
First Line	:	4434 MACARTHUR BLVD NW STE 201
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20007-2550
Country	:	US
Telephone Number	:	202-333-2200
Fax Number	:	202-333-2260

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. HEIDI BLACKWOOD
Credential	:	BA
Telephone Number	:	301-802-4322

Provider Enumeration Date	:	06/08/2021
Last Update Date	:	06/08/2021

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