Healthcare Provider Details

I. General information

NPI: 1235134032
Provider Name (Legal Business Name): EDUARDO A AVILA D.M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11400 ROCKVILLE PIKE STE 805
ROCKVILLE MD
20852-3054
US

IV. Provider business mailing address

11400 ROCKVILLE PIKE STE 805
ROCKVILLE MD
20852-3054
US

V. Phone/Fax

Practice location:
  • Phone: 301-770-3922
  • Fax: 301-770-5105
Mailing address:
  • Phone: 301-770-3922
  • Fax: 301-770-5105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberMD13796
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD16128
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1000783
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: