Provider Demographics
NPI:1033951603
Name:DEFARE, ELBETHEL DEREJE (DDS)
Entity type:Individual
Prefix:DR
First Name:ELBETHEL
Middle Name:DEREJE
Last Name:DEFARE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43154 ASHLEY GREEN DR
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-7045
Mailing Address - Country:US
Mailing Address - Phone:540-326-1711
Mailing Address - Fax:
Practice Address - Street 1:1910 THOMSON DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1009
Practice Address - Country:US
Practice Address - Phone:434-847-4581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014190201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice