Healthcare Provider Details

I. General information

NPI: 1629451430
Provider Name (Legal Business Name): CAPITAL KIDS DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 WISCONSIN AVE NW STE 240
WASHINGTON DC
20016-2143
US

IV. Provider business mailing address

4200 WISCONSIN AVE NW STE 240
WASHINGTON DC
20016-2143
US

V. Phone/Fax

Practice location:
  • Phone: 202-545-7200
  • Fax:
Mailing address:
  • Phone: 202-545-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN1000864
License Number StateDC

VIII. Authorized Official

Name: JESSICA EXELBERT RUBIN
Title or Position: OWNER
Credential: DDS
Phone: 202-545-7200