Healthcare Provider Details

I. General information

NPI: 1558549899
Provider Name (Legal Business Name): COLUMBIA RIVER DENTAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 09/02/2025
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 MARYLAND AVE NE
WASHINGTON DC
20002-7604
US

IV. Provider business mailing address

210 INTERSTATE NORTH PKWY SE STE 300
ATLANTA GA
30339-2233
US

V. Phone/Fax

Practice location:
  • Phone: 770-916-5028
  • Fax:
Mailing address:
  • Phone: 770-916-8143
  • Fax: 770-858-0657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: GAIL DARDEN
Title or Position: DIRECTOR OF PAYOR RELATIONS
Credential:
Phone: 770-916-8143