Healthcare Provider Details

I. General information

NPI: 1003909011
Provider Name (Legal Business Name): THE DENTAL GROUP OF FORT WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6710 OXON HILL RD SUITE #350
OXON HILL MD
20745-1121
US

IV. Provider business mailing address

2203 PARKSIDE DR
MITCHELLVILLE MD
20721-4228
US

V. Phone/Fax

Practice location:
  • Phone: 301-248-3810
  • Fax: 301-449-6746
Mailing address:
  • Phone: 301-390-2575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN4466
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9883
License Number StateMD

VIII. Authorized Official

Name: DR. DANA C. JACKSON
Title or Position: OWNER
Credential: DDS
Phone: 301-248-3810