Basic Information
| Provider Information | |||||||||
| NPI: | 1407205032 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PETWORTH FAMILY DENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4018 GEORGIA AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200115857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028294319 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4018 GEORGIA AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200115857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028294319 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2016 | ||||||||
| LastUpdateDate: | 06/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | BRANCH | ||||||||
| AuthorizedOfficialFirstName: | MAURY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2028294319 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DC | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.