Healthcare Provider Details

I. General information

NPI: 1033598131
Provider Name (Legal Business Name): MISTY DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 34TH ST NE
WASHINGTON DC
20019-1411
US

IV. Provider business mailing address

419 34TH ST NE
WASHINGTON DC
20019-1411
US

V. Phone/Fax

Practice location:
  • Phone: 202-396-6100
  • Fax: 202-388-0987
Mailing address:
  • Phone: 202-396-6100
  • Fax: 202-388-0987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. DERRICK KENDILL EILAND
Title or Position: DOCTOR/OWNER
Credential: DDS
Phone: 202-396-6100