Healthcare Provider Details

I. General information

NPI: 1508014499
Provider Name (Legal Business Name): CAPITOL CLINICAL DENTAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2737 A DEVONSHIRE PLACE NW
WASHINGTON DC
20008-1654
US

IV. Provider business mailing address

2737 A DEVONSHIRE PLACE NW
WASHINGTON DC
20008-1654
US

V. Phone/Fax

Practice location:
  • Phone: 202-232-1117
  • Fax: 202-232-1911
Mailing address:
  • Phone: 202-232-1117
  • Fax: 202-232-1911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN2228
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN1000290
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN1000625
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN3652
License Number StateDC

VIII. Authorized Official

Name: DR. RENEE AVA MCCOY-COLLINS
Title or Position: MANAGING MEMBER
Credential: DDS
Phone: 202-232-1117