Basic Information
| Provider Information | |||||||||
| NPI: | 1366923336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETTAH | ||||||||
| FirstName: | PRECIOUS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 CHESTERWOOD DR | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209062861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565290855 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 311 NH-108 | ||||||||
| Address2: | |||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037492346 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2018 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 16963 | MD | N | Dental Providers | Dentist | General Practice | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223G0001X | 04665 | NH | Y | Dental Providers | Dentist | General Practice |
No ID Information.