=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407205032
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETWORTH FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2016
-----------------------------------------------------
Last Update Date | 06/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4018 GEORGIA AVE NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20011-5857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-829-4319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4018 GEORGIA AVE NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20011-5857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-829-4319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MAURY BRANCH III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 202-829-4319
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------