=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568864718
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPITAL DENTAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2014
-----------------------------------------------------
Last Update Date | 09/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1209 U ST NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20009-4442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-667-8818
-----------------------------------------------------
Fax | 202-667-1024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1209 U ST NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20009-4442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-667-8818
-----------------------------------------------------
Fax | 202-667-1024
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. EDWARD TIPTON BUFORD III
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 202-667-8818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DEN4056
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------