Basic Information
Provider Information | |||||||||
NPI: | 1194880633 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLE | ||||||||
FirstName: | D'AUDRA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 201 KING FARM BLVD APT J102 | ||||||||
Address2: |   | ||||||||
City: | ROCKVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 208506627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3013327225 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2415 MUSGROVE RD | ||||||||
Address2: |   | ||||||||
City: | SILVER SPRING | ||||||||
State: | MD | ||||||||
PostalCode: | 209045200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3019898994 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/26/2006 | ||||||||
LastUpdateDate: | 02/26/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 0401411596 | VA | N |   | Dental Providers | Dentist | General Practice | 122300000X | 14079 | MD | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 9184875 | 05 | VA |   | MEDICAID |