Basic Information
Provider Information | |||||||||
NPI: | 1699062760 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VINSON | ||||||||
FirstName: | RACHEL | ||||||||
MiddleName: | AGUNGA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2345 MARTIN LUTHER KING JR AVE SE | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200205821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2026105690 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6537 ARLINGTON BLVD | ||||||||
Address2: |   | ||||||||
City: | FALLS CHURCH | ||||||||
State: | VA | ||||||||
PostalCode: | 22042 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7035362661 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2011 | ||||||||
LastUpdateDate: | 01/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 15322 | MD | N |   | Dental Providers | Dentist |   | 122300000X | DEN1001036 | DC | Y |   | Dental Providers | Dentist |   |
No ID Information.