Healthcare Provider Details

I. General information

NPI: 1497093652
Provider Name (Legal Business Name): LIGIA S. REQUIAO D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 CONNECTICUT AVENUE, N.W., SUITE #109
WASHINGTON DC
20008
US

IV. Provider business mailing address

4607 CONNECTICUT AVENUE, N.W., SUITE #109
WASHINGTON DC
20008
US

V. Phone/Fax

Practice location:
  • Phone: 202-966-1272
  • Fax: 202-364-2993
Mailing address:
  • Phone: 202-966-1272
  • Fax: 202-364-2993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEM5312
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDEN5312
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: