Healthcare Provider Details

I. General information

NPI: 1396551909
Provider Name (Legal Business Name): COMMUNITY CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7615 ORA GLEN DRIVE
GREENBELT MD
20770
US

IV. Provider business mailing address

8665 GEORGIA AVE
SILVER SPRING MD
20910-3405
US

V. Phone/Fax

Practice location:
  • Phone: 866-877-7258
  • Fax:
Mailing address:
  • Phone: 301-340-7525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALISA BRIGHTLEY
Title or Position: LEAD CREDENTIALING SPECIALIST
Credential:
Phone: 240-297-6758