Healthcare Provider Details

I. General information

NPI: 1255909628
Provider Name (Legal Business Name): DERRELL WASHINGTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 06/14/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 ALCATRAZ AVENUE
BERKELEY CA
94703
US

IV. Provider business mailing address

1503 ALCATRAZ AVENUE
BERKELEY CA
94703-5472
US

V. Phone/Fax

Practice location:
  • Phone: 510-653-6424
  • Fax:
Mailing address:
  • Phone: 317-809-8034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number106166
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: