Healthcare Provider Details

I. General information

NPI: 1356855332
Provider Name (Legal Business Name): ST JUDES DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2802 RHODE ISLAND AVE NE # 1
WASHINGTON DC
20018
US

IV. Provider business mailing address

2802 RHODE ISLAND AVE NE # 1
WASHINGTON DC
20018-2998
US

V. Phone/Fax

Practice location:
  • Phone: 202-269-3387
  • Fax: 202-269-4814
Mailing address:
  • Phone: 202-269-3387
  • Fax: 202-269-4814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1001090
License Number StateDC

VIII. Authorized Official

Name: DR. BRUK E TAEME
Title or Position: DR.
Credential: DDS
Phone: 202-226-9338