=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497105100
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPREHENSIVE DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2016
-----------------------------------------------------
Last Update Date | 06/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 PENNSYLVANIA AVE NW SUITE905
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20006-3405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-466-3599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 PENNSYLVANIA AVE NW SUITE905
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20006-3405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-466-3599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/OWNER
-----------------------------------------------------
Name | DR. MICHAEL KOSTROV
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 202-466-3599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1000589
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------