Healthcare Provider Details

I. General information

NPI: 1922738848
Provider Name (Legal Business Name): SHININGSTARS PEDIATRIC DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 CONNECTICUT AVE NW STE 453
WASHINGTON DC
20008-2356
US

IV. Provider business mailing address

PO BOX 10083
MC LEAN VA
22102-8083
US

V. Phone/Fax

Practice location:
  • Phone: 202-470-3676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GINA CUC PHAM
Title or Position: PRESIDENT
Credential: DDS
Phone: 202-600-4833