Healthcare Provider Details

I. General information

NPI: 1982734075
Provider Name (Legal Business Name): LATAVIAS DEMETRIUS ELLINGTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 12/01/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7425 ARLINGTON RD
BETHESDA MD
20814-5321
US

IV. Provider business mailing address

4835 CORDELL AVE #524
BETHESDA MD
20814-3147
US

V. Phone/Fax

Practice location:
  • Phone: 301-654-8024
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number13834
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN1000572
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number13834
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: