Healthcare Provider Details

I. General information

NPI: 1952961492
Provider Name (Legal Business Name): DEBONAIR DENTAL DC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2737 DEVONSHIRE PL NW STE A
WASHINGTON DC
20008-3479
US

IV. Provider business mailing address

2737 DEVONSHIRE PL NW STE A
WASHINGTON DC
20008-3479
US

V. Phone/Fax

Practice location:
  • Phone: 202-232-1116
  • Fax: 202-232-1911
Mailing address:
  • Phone: 202-232-1116
  • Fax: 202-232-1911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: OTIS COLLINS
Title or Position: COO
Credential:
Phone: 202-232-1116