Healthcare Provider Details

I. General information

NPI: 1619287638
Provider Name (Legal Business Name): COMMUNITY CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8630 FENTON STREET SUITE 1200
SILVER SPRING MD
20910
US

IV. Provider business mailing address

8665 GEORGIA AVE
SILVER SPRING MD
20910-3405
US

V. Phone/Fax

Practice location:
  • Phone: 301-585-1250
  • Fax: 301-585-1250
Mailing address:
  • Phone: 301-340-7525
  • Fax: 301-495-0318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14217
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: PARASTOO GOLESTANI
Title or Position: CHIEF DENTAL OFFICER
Credential: DDS
Phone: 301-340-7525