Healthcare Provider Details

I. General information

NPI: 1023653318
Provider Name (Legal Business Name): JALISA RITA PARKER EFDENTAL ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20020-7007
US

IV. Provider business mailing address

1811 GAINESVILLE ST SE APT F
WASHINGTON DC
20020-3277
US

V. Phone/Fax

Practice location:
  • Phone: 202-621-9260
  • Fax:
Mailing address:
  • Phone: 202-352-8266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberDENA000901
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: