MEDICARE: CAPITOL ORAL, FACIAL & IMPLANT SURGERY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1770082125
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPITOL ORAL, FACIAL & IMPLANT SURGERY PLLC

Provider Business Mailing Address
First Line	:	1325 18TH ST NW STE 203
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20036-6501
Country	:	US
Telephone Number	:	202-716-7626
Fax Number	:

Provider Business Practice Location Address
First Line	:	1325 18TH ST NW STE 203
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20036-6501
Country	:	US
Telephone Number	:	202-716-7626
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. THOMAS SHIN
Credential	:	DMD
Telephone Number	:	202-716-7626

Provider Enumeration Date	:	02/12/2018
Last Update Date	:	02/12/2018

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