Healthcare Provider Details

I. General information

NPI: 1811472798
Provider Name (Legal Business Name): CREATIVE SMILE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2018
Last Update Date: 02/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 16TH STREET, NW SUITE AG 13
WASHINGTON DC
20010-2001
US

IV. Provider business mailing address

1380 MONROE ST NW # 717
WASHINGTON DC
20010-3452
US

V. Phone/Fax

Practice location:
  • Phone: 202-239-7108
  • Fax:
Mailing address:
  • Phone: 120-223-9710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. OLUWOLE AJAGBE
Title or Position: AUTHORIZED RRESENTATIVE
Credential: DDS, MS
Phone: 240-584-6025