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General NPI Number Information
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NPI Number | 1033598131
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Entity Type | Organization
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Legal Business Name | MISTY DENTAL PLLC
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Dates
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Enumeration Date | 05/21/2015
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Last Update Date | 05/21/2015
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Provider Practice Location Address
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Address Line | 419 34TH ST NE
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City | WASHINGTON
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State | DC
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Zip | 20019-1411
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Country | US
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Telephone | 202-396-6100
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Fax | 202-388-0987
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Provider Business Mailing Address
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Address Line | 419 34TH ST NE
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City | WASHINGTON
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State | DC
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Zip | 20019-1411
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Country | US
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Telephone | 202-396-6100
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Fax | 202-388-0987
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | DR. DERRICK KENDILL EILAND
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Credential | DDS
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Telephone | 202-396-6100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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