Basic Information
| Provider Information | |||||||||
| NPI: | 1386756617 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DC SMILES DENTISTRY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 ARCADE UNIT 198747 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372191994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157500343 | ||||||||
| FaxNumber: | 6159861705 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 GEORGIA AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200102501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028295437 | ||||||||
| FaxNumber: | 2028289255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | STUMP | ||||||||
| AuthorizedOfficialFirstName: | JENELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER, LICENSING & CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 6157500343 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 411037400 | 05 | MD | MEDICAID | 038292200 | 05 | DC | MEDICAID |