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| |
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335 C St Se Washington DC 20003-2002 | |
| (989) 980-2807 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Dentist |
| Location | 335 C St Se, Washington, District Of Columbia |
| Authorized Official Name and Position | Tyler J Jacques (REGISTERED AGENT) |
| Authorized Official Contact | 9899802807 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
335 C St Se Washington DC 20003 Ph: (202) 543-0700 | 335 C St Se Washington DC 20003-2002 Ph: (989) 980-2807 |
| NPI Number | 1891225603 |
|---|---|
| Provider Enumeration Date | 06/14/2017 |
| Last Update Date | 09/18/2017 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1891225603 | NPI | - | NPPES |
| 1720369606 | Other | INDIVIDUAL NPI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | DEN1001691 (District Of Columbia) | Primary |
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