Healthcare Provider Details

I. General information

NPI: 1770869877
Provider Name (Legal Business Name): LAELAYE B SHIMELES D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 UNIVERSITY BLVD E
TAKOMA PARK MD
20912-7444
US

IV. Provider business mailing address

1147 UNIVERSITY BLVD E
TAKOMA PARK MD
20912-7444
US

V. Phone/Fax

Practice location:
  • Phone: 703-382-5086
  • Fax:
Mailing address:
  • Phone: 703-382-5086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number14374
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401413828
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: