Basic Information
| Provider Information | |||||||||
| NPI: | 1184079576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBETO | ||||||||
| FirstName: | QUEENATE | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HAMILTON ST NE | ||||||||
| Address2: | APT 213 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200116305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049051338 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043552165 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2016 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 21686738 | NC | Y | Dental Providers | Dentist | General Practice |
No ID Information.