=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376809798
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EJIRO ESI DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2012
-----------------------------------------------------
Last Update Date | 04/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8170 MAPLE LAWN BLVD STE 150
-----------------------------------------------------
City | FULTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20759-2564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-245-0540
-----------------------------------------------------
Fax | 240-554-2532
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2720 S ARLINGTON MILL DR UNIT 711
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22206-3409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-245-0540
-----------------------------------------------------
Fax | 240-554-2532
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 13248
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 0401412336
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DEN1000408
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------