Provider Demographics
NPI:1144631706
Name:DC LIGHT DENTAL, PC
Entity type:Organization
Organization Name:DC LIGHT DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONG
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-347-0100
Mailing Address - Street 1:1331 PENNSYLVANIA AVE NW STE 502
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20004-1771
Mailing Address - Country:US
Mailing Address - Phone:202-347-0100
Mailing Address - Fax:202-347-3703
Practice Address - Street 1:1331 PENNSYLVANIA AVE NW STE 502
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20004-1771
Practice Address - Country:US
Practice Address - Phone:202-347-0100
Practice Address - Fax:202-347-3703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10013301223P0221X
DCDEN10011751223S0112X
DCDEN 100768122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty