Healthcare Provider Details

I. General information

NPI: 1144631706
Provider Name (Legal Business Name): DC LIGHT DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 PENNSYLVANIA AVE NW STE 502
WASHINGTON DC
20004-1771
US

IV. Provider business mailing address

1331 PENNSYLVANIA AVE NW STE 502
WASHINGTON DC
20004-1771
US

V. Phone/Fax

Practice location:
  • Phone: 202-347-0100
  • Fax: 202-347-3703
Mailing address:
  • Phone: 202-347-0100
  • Fax: 202-347-3703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN 100768
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN1001330
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN1001175
License Number StateDC

VIII. Authorized Official

Name: DR. JONG LEE
Title or Position: PRESIDENT
Credential:
Phone: 202-347-0100