Healthcare Provider Details

I. General information

NPI: 1609012988
Provider Name (Legal Business Name): LIDIA TEKLE D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SHERIDAN ST NW
WASHINGTON DC
20011-1150
US

IV. Provider business mailing address

1836 BRUCE PL SE
WASHINGTON DC
20020-2847
US

V. Phone/Fax

Practice location:
  • Phone: 202-726-3300
  • Fax:
Mailing address:
  • Phone: 202-352-9963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN1000747
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401412271
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: