Healthcare Provider Details

I. General information

NPI: 1508213257
Provider Name (Legal Business Name): STEPHANIE BURRELL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BASE NATIONAL CAPITAL REGION CLINIC-USCG HEADQUARTERS 2703 MARTIN LUTHER KING JR AVE SE STOP 7118
WASHINGTON DC
20593-7118
US

IV. Provider business mailing address

BASE NATIONAL CAPITAL REGION CLINIC-USCG HEADQUARTERS 2703 MARTIN LUTHER KING JR AVE SE STOP 7118
WASHINGTON DC
20593-7118
US

V. Phone/Fax

Practice location:
  • Phone: 202-475-5175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS0000007620
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: