=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891341210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. ELIZABETHS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2019
-----------------------------------------------------
Last Update Date | 08/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 ALABAMA AVE SE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20032-4542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-299-5100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 915 SILVER SPRING AVE
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20910-5052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | DR. BERT HALL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 202-299-5100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------