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General NPI Number Information
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NPI Number | 1144631706
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Entity Type | Organization
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Legal Business Name | DC LIGHT DENTAL, PC
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Dates
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Enumeration Date | 05/16/2014
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Last Update Date | 05/16/2014
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Provider Practice Location Address
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Address Line | 1331 PENNSYLVANIA AVE NW STE 502
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City | WASHINGTON
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State | DC
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Zip | 20004-1771
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Country | US
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Telephone | 202-347-0100
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Fax | 202-347-3703
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Provider Business Mailing Address
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Address Line | 1331 PENNSYLVANIA AVE NW STE 502
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City | WASHINGTON
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State | DC
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Zip | 20004-1771
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Country | US
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Telephone | 202-347-0100
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Fax | 202-347-3703
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JONG LEE
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Credential |
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Telephone | 202-347-0100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DEN1001330
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License Number State | DC
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DEN1001175
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License Number State | DC
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DEN 100768
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License Number State | DC
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